- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.20 / $2,207.88 / $8,611.81
| Professional | | $1,237.20 | $2,207.88 | $8,611.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,872.37 / $1,872.37 / $1,872.37
| Facility | | $1,872.37 | $1,872.37 | $1,872.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.05 / $1,980.78 / $3,000.76
| Professional | | $1,183.05 | $1,980.78 | $3,000.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $939.68 / $1,538.17 / $2,428.92
| Facility | | $939.68 | $1,538.17 | $2,428.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.30 / $2,196.08 / $3,160.44
| Professional | | $1,450.30 | $2,196.08 | $3,160.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.41 / $2,729.94 / $3,024.13
| Professional | | $2,264.41 | $2,729.94 | $3,024.13 |