- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.55 / $2,410.96 / $3,623.20
| Professional | | $1,842.55 | $2,410.96 | $3,623.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $3,236.31
| Facility | | $2,290.69 | $2,290.69 | $3,236.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,947.10 / $2,290.69 / $3,993.75
| Professional | | $1,947.10 | $2,290.69 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,770.64 / $2,770.64 / $2,770.64
| Professional | | $2,770.64 | $2,770.64 | $2,770.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.71 / $319.47 / $2,383.14
| Facility | | $185.71 | $319.47 | $2,383.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.32 / $2,041.20 / $3,318.68
| Professional | | $1,385.32 | $2,041.20 | $3,318.68 |