- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.91 / $2,259.62 / $8,840.10
| Professional | | $1,332.91 | $2,259.62 | $8,840.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,008.56 / $2,008.56 / $2,008.56
| Facility | | $2,008.56 | $2,008.56 | $2,008.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.19 / $2,106.39 / $3,098.07
| Professional | | $1,260.19 | $2,106.39 | $3,098.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.86 / $1,553.53 / $2,498.75
| Facility | | $1,007.86 | $1,553.53 | $2,498.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.60 / $2,242.09 / $3,218.88
| Professional | | $1,460.60 | $2,242.09 | $3,218.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.44 / $2,811.35 / $3,105.32
| Professional | | $2,266.44 | $2,811.35 | $3,105.32 |