- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.83 / $1,313.28 / $1,416.93
| Professional | | $1,043.83 | $1,313.28 | $1,416.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,377.76 / $4,562.10 / $5,400.99
| Facility | | $3,377.76 | $4,562.10 | $5,400.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.18 / $1,255.51 / $2,099.73
| Professional | | $1,067.18 | $1,255.51 | $2,099.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,366.32
| Facility | | $1,366.32 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $1,366.32 / $1,366.32
| Professional | | $997.41 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.23 / $1,454.50 / $1,986.44
| Professional | | $1,077.23 | $1,454.50 | $1,986.44 |