- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.07 / $1,894.83 / $4,935.28
| Professional | | $1,180.07 | $1,894.83 | $4,935.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,467.51 / $1,467.51 / $1,467.51
| Facility | | $1,467.51 | $1,467.51 | $1,467.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.09 / $1,467.51 / $1,569.07
| Professional | | $1,073.09 | $1,467.51 | $1,569.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $725.96 / $1,745.25 / $1,788.71
| Facility | | $725.96 | $1,745.25 | $1,788.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.74 / $1,328.75 / $1,916.60
| Professional | | $885.74 | $1,328.75 | $1,916.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.35 / $1,626.00 / $2,552.08
| Professional | | $1,369.35 | $1,626.00 | $2,552.08 |