- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.20 / $3,864.54 / $3,864.54
| Professional | | $1,114.20 | $3,864.54 | $3,864.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.11 / $1,353.12 / $1,353.12
| Facility | | $908.11 | $1,353.12 | $1,353.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.11 / $1,353.12 / $1,353.12
| Professional | | $908.11 | $1,353.12 | $1,353.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $718.47 / $1,288.69 / $1,353.12
| Facility | | $718.47 | $1,288.69 | $1,353.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.58 / $1,038.08 / $1,410.53
| Professional | | $1,015.58 | $1,038.08 | $1,410.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $581.08 / $642.91 / $1,019.65
| Professional | | $581.08 | $642.91 | $1,019.65 |