- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,548.82 / $6,918.31
| Professional | | $1,348.96 | $1,548.82 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.69 / $1,698.24 / $2,570.40
| Facility | | $2.69 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,862.09 / $2,630.27
| Professional | | $1,584.89 | $1,862.09 | $2,630.27 |