- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.48 / $2,428.63 / $6,414.34
| Professional | | $1,625.48 | $2,428.63 | $6,414.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,034.32 / $2,034.32 / $2,034.32
| Facility | | $2,034.32 | $2,034.32 | $2,034.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.48 / $2,034.32 / $2,034.32
| Professional | | $1,334.48 | $2,034.32 | $2,034.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,003.55 / $2,217.80 / $2,330.13
| Facility | | $1,003.55 | $2,217.80 | $2,330.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.21 / $1,799.01 / $2,594.90
| Professional | | $1,199.21 | $1,799.01 | $2,594.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.12 / $2,154.61 / $3,443.77
| Professional | | $1,740.12 | $2,154.61 | $3,443.77 |