- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $2,290.87
| Professional | | $1,445.44 | $2,041.74 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,570.40
| Facility | | $2,398.83 | $2,398.83 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,398.83
| Professional | | $1,737.80 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $4,466.84
| Professional | | $2,754.23 | $3,388.44 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,691.53
| Facility | | $1,445.44 | $1,698.24 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,630.27 / $7,244.36
| Professional | | $1,202.26 | $2,630.27 | $7,244.36 |