- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.86 / $1,067.36 / $1,088.46
| Professional | | $801.86 | $1,067.36 | $1,088.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,594.76 / $3,504.54 / $4,148.97
| Facility | | $2,594.76 | $3,504.54 | $4,148.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.79 / $964.46 / $1,612.99
| Professional | | $819.79 | $964.46 | $1,612.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.52 / $1,316.65 / $1,316.65
| Facility | | $1,061.52 | $1,316.65 | $1,316.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.15 / $1,316.65 / $1,316.65
| Professional | | $961.15 | $1,316.65 | $1,316.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.83 / $1,169.81 / $1,525.95
| Professional | | $861.83 | $1,169.81 | $1,525.95 |