- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $2,137.96
| Professional | | $1,258.93 | $1,819.70 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,818.38
| Facility | | $1,819.70 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,949.84
| Professional | | $1,318.26 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,951.21 / $3,890.45
| Professional | | $2,884.03 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $2,137.96
| Facility | | $1,445.44 | $1,819.70 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,238.72 / $7,943.28
| Professional | | $1,318.26 | $2,238.72 | $7,943.28 |