- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.46 / $1,293.94 / $1,396.06
| Professional | | $1,028.46 | $1,293.94 | $1,396.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,328.01 / $4,494.92 / $5,321.47
| Facility | | $3,328.01 | $4,494.92 | $5,321.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.57 / $1,325.38 / $2,128.62
| Professional | | $1,126.57 | $1,325.38 | $2,128.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.19 / $1,346.19 / $1,411.04
| Facility | | $1,346.19 | $1,346.19 | $1,411.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.72 / $1,346.19 / $1,346.19
| Professional | | $982.72 | $1,346.19 | $1,346.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.80 / $1,363.70 / $1,957.19
| Professional | | $1,074.80 | $1,363.70 | $1,957.19 |