- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.77 / $1,334.82 / $1,481.15
| Professional | | $1,218.77 | $1,334.82 | $1,481.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,004.00 / $7,313.50 / $13,926.85
| Facility | | $4,004.00 | $7,313.50 | $13,926.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.47 / $625.44 / $1,099.20
| Professional | | $411.47 | $625.44 | $1,099.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,410.50 / $2,410.50 / $2,410.50
| Facility | | $2,410.50 | $2,410.50 | $2,410.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.47 / $1,610.98 / $2,907.03
| Professional | | $1,093.47 | $1,610.98 | $2,907.03 |