- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.60 / $1,036.65 / $1,359.61
| Professional | | $1,001.60 | $1,036.65 | $1,359.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,241.10 / $4,377.50 / $5,182.45
| Facility | | $3,241.10 | $4,377.50 | $5,182.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.00 / $1,204.71 / $2,014.78
| Professional | | $1,024.00 | $1,204.71 | $2,014.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.72 / $1,232.72 / $1,325.96
| Facility | | $1,232.72 | $1,232.72 | $1,325.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.89 / $1,232.72 / $1,232.72
| Professional | | $899.89 | $1,232.72 | $1,232.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.64 / $1,295.81 / $1,906.07
| Professional | | $1,033.64 | $1,295.81 | $1,906.07 |