- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.37 / $1,587.35 / $1,751.71
| Professional | | $1,401.37 | $1,587.35 | $1,751.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.54 / $1,286.52 / $2,315.71
| Facility | | $171.54 | $1,286.52 | $2,315.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.73 / $1,385.48 / $2,375.11
| Professional | | $184.73 | $1,385.48 | $2,375.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.64 / $2,217.64 / $3,074.57
| Facility | | $2,217.64 | $2,217.64 | $3,074.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.13 / $2,217.64 / $12,775.94
| Professional | | $2,074.13 | $2,217.64 | $12,775.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.01 / $1,481.52 / $2,373.05
| Professional | | $1,004.01 | $1,481.52 | $2,373.05 |