- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,041.74 / $2,344.23
| Professional | | $1,621.81 | $2,041.74 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,754.23
| Facility | | $2,454.71 | $2,454.71 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,454.71
| Professional | | $1,778.28 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,630.78 / $4,570.88
| Professional | | $2,884.03 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,691.53
| Facility | | $2,238.72 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,818.38 / $7,762.47
| Professional | | $1,288.25 | $2,818.38 | $7,762.47 |