- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $1,737.80
| Professional | | $1,047.13 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,089.30
| Facility | | $1,778.28 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,819.70
| Professional | | $1,288.25 | $1,288.25 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,235.94
| Professional | | $2,238.72 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,548.82 / $1,905.46
| Facility | | $1,412.54 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $5,888.44
| Professional | | $977.24 | $2,137.96 | $5,888.44 |