- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.63 / $1,150.59 / $1,165.17
| Professional | | $847.63 | $1,150.59 | $1,165.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,742.86 / $3,704.60 / $4,385.81
| Facility | | $2,742.86 | $3,704.60 | $4,385.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.59 / $1,019.52 / $1,705.07
| Professional | | $866.59 | $1,019.52 | $1,705.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.13 / $1,254.96 / $1,254.96
| Facility | | $1,122.13 | $1,254.96 | $1,254.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.12 / $1,254.96 / $1,254.96
| Professional | | $916.12 | $1,254.96 | $1,254.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.02 / $1,227.99 / $1,613.06
| Professional | | $911.02 | $1,227.99 | $1,613.06 |