- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,388.44 / $4,365.16
| Professional | | $1,621.81 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,818.38 / $22,908.68
| Facility | | $2,344.23 | $2,818.38 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,365.16 / $4,365.16
| Professional | | $1,258.93 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,630.27 / $2,951.21
| Facility | | $1,621.81 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,071.52 / $1,659.59
| Professional | | $776.25 | $1,071.52 | $1,659.59 |