- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.19 / $2,378.19 / $2,616.01
| Professional | | $2,378.19 | $2,378.19 | $2,616.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,724.01 / $2,168.23 / $6,551.24
| Facility | | $1,724.01 | $2,168.23 | $6,551.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,724.01 / $2,168.23 / $6,551.24
| Facility | | $1,724.01 | $2,168.23 | $6,551.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.65 / $1,290.28 / $1,627.84
| Professional | | $976.65 | $1,290.28 | $1,627.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.33 / $1,291.81 / $1,814.92
| Professional | | $1,239.33 | $1,291.81 | $1,814.92 |