- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,174.90 / $1,348.96
| Professional | | $1,096.48 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,548.13 / $4,265.80
| Professional | | $2,344.23 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $3,388.44
| Professional | | $1,380.38 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $18,197.01
| Facility | | $2,754.23 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,089.30 / $3,890.45
| Professional | | $1,148.15 | $2,089.30 | $3,890.45 |