- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.30 / $1,121.99 / $1,477.28
| Professional | | $1,088.30 | $1,121.99 | $1,477.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,521.64 / $4,756.45 / $5,631.08
| Facility | | $3,521.64 | $4,756.45 | $5,631.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.49 / $1,402.49 / $2,252.46
| Professional | | $1,402.49 | $1,402.49 | $2,252.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.30 / $1,167.30 / $1,440.73
| Facility | | $1,167.30 | $1,167.30 | $1,440.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.13 / $1,167.30 / $1,167.30
| Professional | | $852.13 | $1,167.30 | $1,167.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.11 / $1,402.49 / $2,071.06
| Professional | | $1,123.11 | $1,402.49 | $2,071.06 |