- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,067.11 / $2,975.51
| Professional | | $1,028.55 | $1,067.11 | $2,975.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $689.32 / $689.32 / $1,930.67
| Facility | | $689.32 | $689.32 | $1,930.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.32 / $1,092.83 / $1,232.11
| Professional | | $689.32 | $1,092.83 | $1,232.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.58 / $713.74 / $1,339.26
| Facility | | $450.58 | $713.74 | $1,339.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.23 / $1,285.69 / $1,339.26
| Professional | | $636.23 | $1,285.69 | $1,339.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.41 / $1,071.41 / $1,071.41
| Professional | | $1,071.41 | $1,071.41 | $1,071.41 |