- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.12 / $1,596.48 / $1,696.40
| Professional | | $1,357.12 | $1,596.48 | $1,696.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.88 / $1,259.22 / $2,266.41
| Facility | | $167.88 | $1,259.22 | $2,266.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.80 / $1,356.08 / $2,324.79
| Professional | | $180.80 | $1,356.08 | $2,324.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $3,027.07
| Facility | | $1,460.50 | $1,460.50 | $3,027.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,825.63 / $1,916.91
| Professional | | $1,460.50 | $1,825.63 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.64 / $1,744.23 / $1,808.17
| Professional | | $1,641.64 | $1,744.23 | $1,808.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.51 / $1,288.68 / $1,941.20
| Professional | | $907.51 | $1,288.68 | $1,941.20 |