- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.78 / $1,097.07 / $5,568.44
| Professional | | $1,089.78 | $1,097.07 | $5,568.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,657.85 / $1,657.85 / $1,657.85
| Facility | | $1,657.85 | $1,657.85 | $1,657.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.84 / $1,657.85 / $1,779.76
| Professional | | $1,178.84 | $1,657.85 | $1,779.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $820.02 / $1,966.90 / $2,032.22
| Facility | | $820.02 | $1,966.90 | $2,032.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.91 / $1,501.52 / $2,165.80
| Professional | | $1,000.91 | $1,501.52 | $2,165.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.25 / $1,818.31 / $2,885.07
| Professional | | $1,543.25 | $1,818.31 | $2,885.07 |