- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,380.38 / $2,398.83
| Professional | | $1,230.27 | $1,380.38 | $2,398.83 |
- 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
- $2,691.53 / $3,981.07 / $4,786.30
| Professional | | $2,691.53 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,398.83 / $3,890.45
| Professional | | $1,479.11 | $2,398.83 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,168.69 / $14,125.38
| Facility | | $2,754.23 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $5,011.87
| Professional | | $1,380.38 | $2,398.83 | $5,011.87 |