- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.32 / $1,222.11 / $1,252.69
| Professional | | $900.32 | $1,222.11 | $1,252.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,913.36 / $3,934.85 / $4,658.41
| Facility | | $2,913.36 | $3,934.85 | $4,658.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.46 / $1,082.89 / $1,811.04
| Professional | | $920.46 | $1,082.89 | $1,811.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.89 / $1,637.27 / $1,637.27
| Facility | | $1,191.89 | $1,637.27 | $1,637.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.21 / $1,637.27 / $1,637.27
| Professional | | $1,195.21 | $1,637.27 | $1,637.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.12 / $1,313.26 / $1,713.33
| Professional | | $929.12 | $1,313.26 | $1,713.33 |