- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.05 / $1,102.28 / $1,267.54
| Professional | | $1,058.05 | $1,102.28 | $1,267.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,670.08 / $3,290.06 / $6,346.30
| Facility | | $1,670.08 | $3,290.06 | $6,346.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.34 / $1,354.64 / $1,693.30
| Professional | | $551.34 | $1,354.64 | $1,693.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,670.08 / $3,290.06 / $6,346.30
| Facility | | $1,670.08 | $3,290.06 | $6,346.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.34 / $1,459.69 / $2,470.19
| Professional | | $1,030.34 | $1,459.69 | $2,470.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.84 / $431.84 / $1,102.69
| Professional | | $431.84 | $431.84 | $1,102.69 |