- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.52 / $1,707.70 / $7,820.04
| Professional | | $1,306.52 | $1,707.70 | $7,820.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,377.67 / $2,377.67 / $2,377.67
| Facility | | $2,377.67 | $2,377.67 | $2,377.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.31 / $2,377.67 / $2,377.67
| Professional | | $1,779.31 | $2,377.67 | $2,377.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,377.67 / $2,642.25 / $2,681.17
| Facility | | $2,377.67 | $2,642.25 | $2,681.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.72 / $2,063.71 / $3,152.10
| Professional | | $1,456.72 | $2,063.71 | $3,152.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.33 / $2,642.24 / $4,166.18
| Professional | | $2,086.33 | $2,642.24 | $4,166.18 |