- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.02 / $1,850.27 / $3,267.98
| Professional | | $1,414.02 | $1,850.27 | $3,267.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.86 / $2,416.31 / $3,982.50
| Professional | | $2,053.86 | $2,416.31 | $3,982.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.19 / $2,457.19 / $2,457.19
| Professional | | $2,457.19 | $2,457.19 | $2,457.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,221.41 / $1,533.61 / $2,506.91
| Professional | | $1,221.41 | $1,533.61 | $2,506.91 |