- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.51 / $1,113.96 / $1,312.12
| Professional | | $1,023.51 | $1,113.96 | $1,312.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.38 / $902.84 / $1,523.08
| Facility | | $120.38 | $902.84 | $1,523.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.63 / $972.29 / $1,640.24
| Professional | | $129.63 | $972.29 | $1,640.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $2,527.53
| Facility | | $1,217.05 | $1,217.05 | $2,527.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,455.57 / $8,989.59
| Professional | | $1,217.05 | $1,455.57 | $8,989.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.81 / $1,118.19 / $2,084.21
| Professional | | $881.81 | $1,118.19 | $2,084.21 |