- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $2,630.27
| Professional | | $1,412.54 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $2,630.27
| Facility | | $2,454.71 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,630.27
| Professional | | $1,905.46 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $4,466.84
| Professional | | $2,570.40 | $3,235.94 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $2,630.27
| Facility | | $1,862.09 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,511.89 / $6,918.31
| Professional | | $1,148.15 | $2,511.89 | $6,918.31 |