- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.85 / $1,789.39 / $2,057.17
| Professional | | $1,493.85 | $1,789.39 | $2,057.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.67 / $1,624.56 / $2,505.98
| Facility | | $199.67 | $1,624.56 | $2,505.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.03 / $1,644.52 / $2,212.13
| Professional | | $215.03 | $1,644.52 | $2,212.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $3,703.34
| Facility | | $1,786.79 | $1,786.79 | $3,703.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $14,463.37
| Professional | | $1,786.79 | $1,786.79 | $14,463.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.26 / $1,562.76 / $2,136.81
| Professional | | $1,110.26 | $1,562.76 | $2,136.81 |