- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,548.82 / $6,606.93
| Professional | | $1,348.96 | $1,548.82 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.63 / $2,187.76 / $2,511.89
| Facility | | $2.63 | $2,187.76 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,754.23
| Professional | | $1,479.11 | $1,778.28 | $2,754.23 |