- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.21 / $1,429.51 / $7,374.23
| Professional | | $1,287.21 | $1,429.51 | $7,374.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,249.90 / $2,249.90 / $2,249.90
| Facility | | $2,249.90 | $2,249.90 | $2,249.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.71 / $2,238.33 / $4,111.37
| Professional | | $1,384.71 | $2,238.33 | $4,111.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.93 / $1,902.36 / $2,795.02
| Facility | | $1,384.93 | $1,902.36 | $2,795.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.43 / $2,291.60 / $3,818.62
| Professional | | $1,436.43 | $2,291.60 | $3,818.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.02 / $2,462.66 / $3,937.72
| Professional | | $2,041.02 | $2,462.66 | $3,937.72 |