- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.45 / $1,670.37 / $8,804.89
| Professional | | $1,424.45 | $1,670.37 | $8,804.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.20 / $2,694.20 / $2,694.20
| Facility | | $2,694.20 | $2,694.20 | $2,694.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.88 / $2,688.94 / $4,859.77
| Professional | | $1,607.88 | $2,688.94 | $4,859.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.62 / $2,227.13 / $3,084.07
| Facility | | $1,659.62 | $2,227.13 | $3,084.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.96 / $2,752.08 / $4,585.93
| Professional | | $1,687.96 | $2,752.08 | $4,585.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,346.23 / $2,869.76 / $4,293.12
| Professional | | $2,346.23 | $2,869.76 | $4,293.12 |