- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.66 / $1,229.55 / $6,484.41
| Professional | | $1,051.66 | $1,229.55 | $6,484.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,988.58 / $1,988.58 / $1,988.58
| Facility | | $1,988.58 | $1,988.58 | $1,988.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.50 / $1,988.58 / $3,120.25
| Professional | | $1,183.50 | $1,988.58 | $3,120.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,163.03 / $1,665.86 / $2,282.69
| Facility | | $1,163.03 | $1,665.86 | $2,282.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.94 / $2,029.01 / $3,381.06
| Professional | | $1,241.94 | $2,029.01 | $3,381.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.49 / $2,158.65 / $3,480.78
| Professional | | $1,723.49 | $2,158.65 | $3,480.78 |