- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,354.35 / $1,815.06 / $3,424.39
| Professional | | $1,354.35 | $1,815.06 | $3,424.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $4,729.50
| Professional | | $2,271.73 | $2,672.64 | $4,729.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,753.11 / $3,753.11 / $4,039.39
| Professional | | $3,753.11 | $3,753.11 | $4,039.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.05 / $2,729.70 / $2,729.70
| Professional | | $299.05 | $2,729.70 | $2,729.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.19 / $2,047.28 / $3,278.37
| Professional | | $1,700.19 | $2,047.28 | $3,278.37 |