- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $1,819.70
| Professional | | $1,047.13 | $1,479.11 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,862.09
| Facility | | $1,778.28 | $1,778.28 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,862.09
| Professional | | $1,318.26 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $3,235.94
| Professional | | $1,995.26 | $2,454.71 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $1,949.84
| Facility | | $1,445.44 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,905.46 / $5,248.07
| Professional | | $870.96 | $1,905.46 | $5,248.07 |