- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $2,818.38
| Professional | | $1,584.89 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,630.27 / $6,760.83
| Facility | | $1,479.11 | $2,630.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $4,365.16
| Professional | | $2,884.03 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,019.95 / $8,128.31
| Facility | | $794.33 | $3,019.95 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,311.31 / $8,511.38
| Facility | | $794.33 | $3,311.31 | $8,511.38 |