- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.02 / $1,048.02 / $1,209.26
| Professional | | $1,048.02 | $1,048.02 | $1,209.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.48 / $1,006.48 / $1,578.49
| Facility | | $1,006.48 | $1,006.48 | $1,578.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.73 / $734.73 / $1,003.20
| Professional | | $734.73 | $734.73 | $1,003.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,006.48 / $1,006.48 / $1,578.49
| Facility | | $1,006.48 | $1,006.48 | $1,578.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.73 / $734.73 / $1,003.20
| Professional | | $734.73 | $734.73 | $1,003.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $820.00 / $820.00 / $820.00
| Facility | | $820.00 | $820.00 | $820.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.64 / $1,272.19 / $2,482.77
| Professional | | $729.64 | $1,272.19 | $2,482.77 |