- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $3,090.30
| Professional | | $1,659.59 | $1,905.46 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,715.35
| Facility | | $2,884.03 | $2,884.03 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,162.28
| Professional | | $2,454.71 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,202.26 / $2,398.83
| Facility | | $489.78 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $2,454.71
| Professional | | $1,445.44 | $1,621.81 | $2,454.71 |