- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.34 / $1,195.34 / $1,494.19
| Professional | | $1,195.34 | $1,195.34 | $1,494.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.22 / $2,771.52 / $2,771.52
| Facility | | $957.22 | $2,771.52 | $2,771.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,772.97 / $3,772.97 / $3,772.97
| Professional | | $3,772.97 | $3,772.97 | $3,772.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.46 / $961.55 / $1,470.00
| Facility | | $583.46 | $961.55 | $1,470.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.07 / $1,060.56 / $1,344.00
| Professional | | $640.07 | $1,060.56 | $1,344.00 |