- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $2,398.83
| Professional | | $1,479.11 | $1,479.11 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $1,445.44 / $1,819.70
| Professional | | $186.21 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $3,630.78
| Professional | | $2,691.53 | $2,818.38 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $954.99 / $1,737.80
| Facility | | $128.82 | $954.99 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,778.28 / $2,454.71
| Professional | | $977.24 | $1,778.28 | $2,454.71 |