- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.01 / $1,695.32 / $2,119.15
| Professional | | $1,185.01 | $1,695.32 | $2,119.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $980.14 / $1,636.43 / $1,747.87
| Facility | | $980.14 | $1,636.43 | $1,747.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.00 / $3,870.00 / $3,870.00
| Professional | | $1,316.00 | $3,870.00 | $3,870.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,247.00 / $1,247.00 / $1,247.00
| Facility | | $1,247.00 | $1,247.00 | $1,247.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.83 / $1,247.00 / $1,524.93
| Professional | | $1,027.83 | $1,247.00 | $1,524.93 |