- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $7,943.28
| Professional | | $1,202.26 | $1,445.44 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.63 / $2,137.96 / $2,454.71
| Facility | | $2.63 | $2,137.96 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,511.89
| Professional | | $1,479.11 | $1,737.80 | $2,511.89 |