- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.07 / $1,796.67 / $1,832.07
| Professional | | $1,571.07 | $1,796.67 | $1,832.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.17 / $2,566.01 / $3,082.72
| Facility | | $2,056.17 | $2,566.01 | $3,082.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.42 / $986.38 / $986.38
| Professional | | $838.42 | $986.38 | $986.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,878.74 / $4,384.85 / $5,060.64
| Facility | | $2,878.74 | $4,384.85 | $5,060.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.87 / $1,155.99 / $1,293.01
| Professional | | $822.87 | $1,155.99 | $1,293.01 |