- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $2,691.53
| Professional | | $1,412.54 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,511.89
| Facility | | $2,454.71 | $2,454.71 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,630.27
| Professional | | $1,819.70 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,311.31 / $4,365.16
| Professional | | $2,630.27 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,630.27
| Facility | | $2,187.76 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,570.40 / $7,079.46
| Professional | | $1,174.90 | $2,570.40 | $7,079.46 |