- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.51 / $1,454.75 / $7,511.28
| Professional | | $1,305.51 | $1,454.75 | $7,511.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,287.23 / $2,287.23 / $2,287.23
| Facility | | $2,287.23 | $2,287.23 | $2,287.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.42 / $2,287.23 / $4,244.47
| Professional | | $1,380.42 | $2,287.23 | $4,244.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.26 / $1,904.80 / $2,789.33
| Facility | | $1,268.26 | $1,904.80 | $2,789.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.21 / $2,333.12 / $3,887.81
| Professional | | $1,475.21 | $2,333.12 | $3,887.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.67 / $2,496.69 / $3,075.56
| Professional | | $2,002.67 | $2,496.69 | $3,075.56 |