- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.77 / $1,373.77 / $1,956.69
| Professional | | $1,373.77 | $1,373.77 | $1,956.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.30 / $1,169.36 / $2,309.41
| Facility | | $903.30 | $1,169.36 | $2,309.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.41 / $960.48 / $960.48
| Professional | | $816.41 | $960.48 | $960.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,432.33 / $2,517.94 / $4,386.47
| Facility | | $1,432.33 | $2,517.94 | $4,386.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.54 / $1,050.25 / $1,293.40
| Professional | | $71.54 | $1,050.25 | $1,293.40 |