- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.41 / $1,052.56 / $1,171.17
| Professional | | $775.41 | $1,052.56 | $1,171.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,509.16 / $3,388.96 / $4,012.13
| Facility | | $2,509.16 | $3,388.96 | $4,012.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.15 / $1,159.15 / $1,604.89
| Professional | | $1,159.15 | $1,159.15 | $1,604.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.52 / $1,530.70 / $1,530.70
| Facility | | $1,026.52 | $1,530.70 | $1,530.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.41 / $1,117.41 / $1,117.41
| Professional | | $1,117.41 | $1,117.41 | $1,117.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.21 / $1,013.51 / $1,475.63
| Professional | | $800.21 | $1,013.51 | $1,475.63 |