- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,041.74
| Professional | | $1,698.24 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $26,302.68 / $26,302.68
| Facility | | $8,511.38 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $2,951.21
| Facility | | $776.25 | $1,122.02 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $512.86 / $616.60
| Professional | | $416.87 | $512.86 | $616.60 |