- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.12 / $1,075.24 / $1,158.74
| Professional | | $792.12 | $1,075.24 | $1,158.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,563.21 / $3,461.95 / $4,098.55
| Facility | | $2,563.21 | $3,461.95 | $4,098.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.50 / $1,184.11 / $1,639.45
| Professional | | $1,006.50 | $1,184.11 | $1,639.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,048.63 / $1,132.82 / $1,132.82
| Facility | | $1,048.63 | $1,132.82 | $1,132.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.96 / $826.96 / $826.96
| Professional | | $826.96 | $826.96 | $826.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.45 / $1,155.58 / $1,507.41
| Professional | | $817.45 | $1,155.58 | $1,507.41 |