- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.61 / $1,369.38 / $1,498.10
| Professional | | $1,103.61 | $1,369.38 | $1,498.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,571.23 / $4,823.42 / $5,710.36
| Facility | | $3,571.23 | $4,823.42 | $5,710.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.25 / $1,422.25 / $2,284.19
| Professional | | $1,422.25 | $1,422.25 | $2,284.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $1,461.04
| Facility | | $1,424.68 | $1,424.68 | $1,461.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $1,040.02
| Professional | | $1,040.02 | $1,040.02 | $1,040.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.94 / $1,442.50 / $2,100.21
| Professional | | $1,138.94 | $1,442.50 | $2,100.21 |