- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.57 / $1,381.57 / $6,826.43
| Professional | | $1,381.57 | $1,381.57 | $6,826.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,013.29 / $2,013.29 / $2,013.29
| Facility | | $2,013.29 | $2,013.29 | $2,013.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.81 / $2,013.29 / $2,174.35
| Professional | | $1,476.81 | $2,013.29 | $2,174.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $995.68 / $2,397.19 / $2,463.59
| Facility | | $995.68 | $2,397.19 | $2,463.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.33 / $1,826.18 / $2,634.10
| Professional | | $1,217.33 | $1,826.18 | $2,634.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.88 / $2,255.40 / $3,504.83
| Professional | | $1,880.88 | $2,255.40 | $3,504.83 |