- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,659.59
| Professional | | $1,318.26 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $1,698.24
| Facility | | $831.76 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,071.52 / $4,466.84
| Professional | | $562.34 | $1,071.52 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,412.54
| Professional | | $1,348.96 | $1,348.96 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $1,202.26
| Professional | | $851.14 | $1,047.13 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,230.27 / $1,659.59
| Professional | | $676.08 | $1,230.27 | $1,659.59 |