- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.94 / $1,415.10 / $1,503.68
| Professional | | $1,202.94 | $1,415.10 | $1,503.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.83 / $183.18 / $2,009.22
| Facility | | $148.83 | $183.18 | $2,009.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.83 / $160.28 / $2,163.77
| Professional | | $148.83 | $160.28 | $2,163.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $2,305.69
| Facility | | $975.26 | $975.26 | $2,305.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $975.26 / $1,659.96
| Professional | | $161.82 | $975.26 | $1,659.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.79 / $1,602.79 / $1,602.79
| Professional | | $1,602.79 | $1,602.79 | $1,602.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.41 / $970.99 / $1,638.73
| Professional | | $804.41 | $970.99 | $1,638.73 |