- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.13 / $1,324.67 / $1,395.61
| Professional | | $1,028.13 | $1,324.67 | $1,395.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,326.94 / $4,493.43 / $5,319.71
| Facility | | $3,326.94 | $4,493.43 | $5,319.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.13 / $1,236.61 / $2,068.14
| Professional | | $1,051.13 | $1,236.61 | $2,068.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.14 / $1,618.14 / $1,618.14
| Facility | | $1,618.14 | $1,618.14 | $1,618.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.24 / $1,618.14 / $1,618.14
| Professional | | $1,181.24 | $1,618.14 | $1,618.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.17 / $1,173.93 / $1,956.55
| Professional | | $919.17 | $1,173.93 | $1,956.55 |