- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.04 / $1,117.55 / $1,205.45
| Professional | | $888.04 | $1,117.55 | $1,205.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,873.60 / $3,881.18 / $4,594.85
| Facility | | $2,873.60 | $3,881.18 | $4,594.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.11 / $1,068.11 / $1,786.34
| Professional | | $1,068.11 | $1,068.11 | $1,786.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.68 / $1,162.68 / $1,162.68
| Facility | | $1,162.68 | $1,162.68 | $1,162.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.28 / $1,162.68 / $1,162.68
| Professional | | $988.28 | $1,162.68 | $1,162.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.74 / $1,160.71 / $1,689.95
| Professional | | $32.74 | $1,160.71 | $1,689.95 |