- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.35 / $1,202.46 / $1,583.25
| Professional | | $1,166.35 | $1,202.46 | $1,583.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,774.24 / $5,097.60 / $6,034.97
| Facility | | $3,774.24 | $5,097.60 | $6,034.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.45 / $1,402.88 / $2,346.21
| Professional | | $1,192.45 | $1,402.88 | $2,346.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.10 / $1,304.10 / $1,304.10
| Facility | | $1,304.10 | $1,304.10 | $1,304.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $1,304.10 / $1,304.10
| Professional | | $952.00 | $1,304.10 | $1,304.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.93 / $1,331.77 / $2,219.61
| Professional | | $906.93 | $1,331.77 | $2,219.61 |