- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.01 / $1,341.53 / $6,333.27
| Professional | | $1,213.01 | $1,341.53 | $6,333.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.26 / $1,931.26 / $1,931.26
| Facility | | $1,931.26 | $1,931.26 | $1,931.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.34 / $1,931.26 / $1,931.26
| Professional | | $1,403.34 | $1,931.26 | $1,931.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,931.26 / $2,230.15 / $2,414.89
| Facility | | $1,931.26 | $2,230.15 | $2,414.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.48 / $1,670.96 / $2,552.19
| Professional | | $1,179.48 | $1,670.96 | $2,552.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,749.81 / $2,149.19 / $3,379.95
| Professional | | $1,749.81 | $2,149.19 | $3,379.95 |