- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.31 / $1,011.93 / $1,091.80
| Professional | | $804.31 | $1,011.93 | $1,091.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,602.69 / $3,515.29 / $4,161.70
| Facility | | $2,602.69 | $3,515.29 | $4,161.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.30 / $967.41 / $1,617.94
| Professional | | $822.30 | $967.41 | $1,617.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.56 / $1,329.56 / $1,329.56
| Facility | | $1,329.56 | $1,329.56 | $1,329.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.58 / $970.58 / $970.58
| Professional | | $970.58 | $970.58 | $970.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.04 / $1,173.39 / $1,530.63
| Professional | | $830.04 | $1,173.39 | $1,530.63 |