- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.79 / $1,487.32 / $7,841.36
| Professional | | $1,309.79 | $1,487.32 | $7,841.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.80 / $2,400.80 / $2,400.80
| Facility | | $2,400.80 | $2,400.80 | $2,400.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.81 / $2,400.59 / $4,124.83
| Professional | | $1,434.81 | $2,400.59 | $4,124.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,468.83 / $2,039.70 / $2,817.79
| Facility | | $1,468.83 | $2,039.70 | $2,817.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.68 / $2,451.19 / $4,084.58
| Professional | | $1,503.68 | $2,451.19 | $4,084.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,127.87 / $2,585.12 / $4,205.04
| Professional | | $2,127.87 | $2,585.12 | $4,205.04 |