- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,202.26 / $2,187.76
| Professional | | $1,122.02 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,265.80 / $4,265.80
| Professional | | $2,818.38 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,290.87 / $3,388.44
| Professional | | $1,479.11 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,630.27 / $10,471.29
| Facility | | $1,380.38 | $2,630.27 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,187.76 / $4,677.35
| Professional | | $1,288.25 | $2,187.76 | $4,677.35 |