- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.31 / $1,416.89 / $6,503.63
| Professional | | $1,258.31 | $1,416.89 | $6,503.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,983.32 / $1,983.32 / $1,983.32
| Facility | | $1,983.32 | $1,983.32 | $1,983.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.20 / $1,983.32 / $1,983.32
| Professional | | $1,475.20 | $1,983.32 | $1,983.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,983.32 / $2,323.75 / $2,653.34
| Facility | | $1,983.32 | $2,323.75 | $2,653.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.85 / $1,715.42 / $2,620.10
| Professional | | $1,210.85 | $1,715.42 | $2,620.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.26 / $2,208.01 / $3,469.67
| Professional | | $1,823.26 | $2,208.01 | $3,469.67 |