- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.56 / $1,326.99 / $6,978.27
| Professional | | $1,318.56 | $1,326.99 | $6,978.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,112.66 / $2,112.66 / $2,112.66
| Facility | | $2,112.66 | $2,112.66 | $2,112.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.07 / $2,112.66 / $2,112.66
| Professional | | $1,549.07 | $2,112.66 | $2,112.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,112.66 / $2,640.69 / $2,656.55
| Facility | | $2,112.66 | $2,640.69 | $2,656.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.18 / $1,840.53 / $2,811.20
| Professional | | $1,299.18 | $1,840.53 | $2,811.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,056.08 / $2,372.40 / $3,707.40
| Professional | | $2,056.08 | $2,372.40 | $3,707.40 |