- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,949.84 / $2,344.23
| Professional | | $1,348.96 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,951.21
| Facility | | $2,454.71 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,454.71
| Professional | | $1,819.70 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,388.44 / $4,265.80
| Professional | | $3,090.30 | $3,388.44 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,949.84 / $2,511.89
| Facility | | $1,698.24 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,019.95 / $8,317.64
| Professional | | $1,380.38 | $3,019.95 | $8,317.64 |