- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.13 / $1,221.63 / $1,527.04
| Professional | | $1,152.13 | $1,221.63 | $1,527.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.22 / $1,096.52 / $1,702.09
| Facility | | $655.22 | $1,096.52 | $1,702.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,885.41 / $2,885.41 / $2,885.41
| Professional | | $2,885.41 | $2,885.41 | $2,885.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $852.48 / $852.48 / $1,062.00
| Facility | | $852.48 | $852.48 | $1,062.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.48 / $1,098.00 / $1,314.98
| Professional | | $852.48 | $1,098.00 | $1,314.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.57 / $1,086.71 / $1,104.88
| Professional | | $605.57 | $1,086.71 | $1,104.88 |