- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.53 / $1,505.73 / $7,948.18
| Professional | | $1,189.53 | $1,505.73 | $7,948.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,423.41 / $2,423.41 / $2,423.41
| Facility | | $2,423.41 | $2,423.41 | $2,423.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.43 / $2,423.41 / $3,846.09
| Professional | | $1,378.43 | $2,423.41 | $3,846.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.56 / $1,906.16 / $2,633.73
| Facility | | $1,494.56 | $1,906.16 | $2,633.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.89 / $2,484.09 / $4,139.39
| Professional | | $1,507.89 | $2,484.09 | $4,139.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,102.77 / $2,460.69 / $3,229.30
| Professional | | $2,102.77 | $2,460.69 | $3,229.30 |