- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.64 / $982.39 / $1,059.65
| Professional | | $780.64 | $982.39 | $1,059.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,526.07 / $3,411.79 / $4,039.17
| Facility | | $2,526.07 | $3,411.79 | $4,039.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.11 / $1,207.20 / $1,615.70
| Professional | | $1,026.11 | $1,207.20 | $1,615.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.07 / $1,022.07 / $1,022.07
| Facility | | $1,022.07 | $1,022.07 | $1,022.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.76 / $1,022.07 / $1,022.07
| Professional | | $868.76 | $1,022.07 | $1,022.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.80 / $1,138.84 / $1,485.57
| Professional | | $804.80 | $1,138.84 | $1,485.57 |