- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.50 / $1,202.23 / $1,984.38
| Professional | | $1,112.50 | $1,202.23 | $1,984.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.86 / $2,075.86 / $2,075.86
| Facility | | $2,075.86 | $2,075.86 | $2,075.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.31 / $2,075.86 / $2,271.55
| Professional | | $1,518.31 | $2,075.86 | $2,271.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,022.02 / $2,431.65 / $2,530.63
| Facility | | $1,022.02 | $2,431.65 | $2,530.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.11 / $1,902.38 / $2,744.00
| Professional | | $1,268.11 | $1,902.38 | $2,744.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.92 / $2,313.59 / $3,632.47
| Professional | | $1,907.92 | $2,313.59 | $3,632.47 |