- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.59 / $1,250.07 / $1,348.73
| Professional | | $993.59 | $1,250.07 | $1,348.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,215.17 / $4,342.55 / $5,141.06
| Facility | | $3,215.17 | $4,342.55 | $5,141.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.51 / $1,485.31 / $2,056.46
| Professional | | $1,262.51 | $1,485.31 | $2,056.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.55 / $1,300.55 / $1,300.55
| Facility | | $1,300.55 | $1,300.55 | $1,300.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.40 / $949.40 / $949.40
| Professional | | $949.40 | $949.40 | $949.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.30 / $1,134.50 / $1,890.83
| Professional | | $888.30 | $1,134.50 | $1,890.83 |