- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.89 / $1,537.04 / $3,800.68
| Professional | | $1,297.89 | $1,537.04 | $3,800.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,427.62 / $2,427.62 / $2,427.62
| Facility | | $2,427.62 | $2,427.62 | $2,427.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.52 / $2,427.62 / $2,749.37
| Professional | | $1,271.52 | $2,427.62 | $2,749.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.94 / $1,629.79 / $2,427.62
| Facility | | $1,202.94 | $1,629.79 | $2,427.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.34 / $2,427.62 / $3,203.20
| Professional | | $1,480.34 | $2,427.62 | $3,203.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.71 / $2,561.01 / $2,965.39
| Professional | | $2,111.71 | $2,561.01 | $2,965.39 |