- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.70 / $1,274.11 / $1,354.60
| Professional | | $1,015.70 | $1,274.11 | $1,354.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.86 / $1,933.19 / $2,575.08
| Facility | | $1,855.86 | $1,933.19 | $2,575.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.55 / $1,933.19 / $3,585.75
| Professional | | $1,546.55 | $1,933.19 | $3,585.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,014.52 / $2,014.52 / $2,014.52
| Facility | | $2,014.52 | $2,014.52 | $2,014.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.35 / $771.56 / $1,291.70
| Professional | | $723.35 | $771.56 | $1,291.70 |