- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.28 / $1,473.83 / $1,657.15
| Professional | | $1,306.28 | $1,473.83 | $1,657.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.27 / $1,194.52 / $2,082.48
| Facility | | $159.27 | $1,194.52 | $2,082.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.52 / $1,286.40 / $2,205.25
| Professional | | $171.52 | $1,286.40 | $2,205.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,860.35
| Facility | | $1,772.06 | $1,772.06 | $2,860.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,913.55 / $2,111.63
| Professional | | $1,772.06 | $1,913.55 | $2,111.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.84 / $1,131.32 / $1,791.25
| Facility | | $150.84 | $1,131.32 | $1,791.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.92 / $1,364.31 / $2,358.66
| Professional | | $997.92 | $1,364.31 | $2,358.66 |