- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.08 / $1,644.85 / $1,686.06
| Professional | | $1,242.08 | $1,644.85 | $1,686.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,019.31 / $5,428.63 / $6,426.86
| Facility | | $4,019.31 | $5,428.63 | $6,426.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.28 / $1,856.80 / $2,570.78
| Professional | | $1,578.28 | $1,856.80 | $2,570.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.34 / $1,711.28 / $1,711.28
| Facility | | $1,644.34 | $1,711.28 | $1,711.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.23 / $1,711.28 / $1,711.28
| Professional | | $1,249.23 | $1,711.28 | $1,711.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.83 / $1,684.33 / $2,363.73
| Professional | | $1,281.83 | $1,684.33 | $2,363.73 |