- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $1,698.24
| Professional | | $1,174.90 | $1,479.11 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,778.28
| Professional | | $1,318.26 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $3,311.31
| Professional | | $2,089.30 | $2,630.27 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,949.84
| Facility | | $1,621.81 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,041.74 / $5,623.41
| Professional | | $933.25 | $2,041.74 | $5,623.41 |