- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $2,570.40
| Professional | | $1,659.59 | $2,238.72 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,090.30
| Facility | | $2,951.21 | $2,951.21 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,951.21
| Professional | | $2,187.76 | $2,187.76 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,715.35 / $4,897.79
| Professional | | $3,235.94 | $3,715.35 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $2,951.21
| Facility | | $2,041.74 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,162.28 / $8,709.64
| Professional | | $1,445.44 | $3,162.28 | $8,709.64 |