- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.36 / $6,225.25 / $7,918.60
| Professional | | $1,244.36 | $6,225.25 | $7,918.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.33 / $1,861.33 / $1,861.33
| Facility | | $1,861.33 | $1,861.33 | $1,861.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.27 / $1,861.33 / $2,383.44
| Professional | | $1,444.27 | $1,861.33 | $2,383.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.20 / $2,328.94 / $2,573.01
| Facility | | $1,154.20 | $2,328.94 | $2,573.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.74 / $1,861.33 / $2,607.80
| Professional | | $1,219.74 | $1,861.33 | $2,607.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.18 / $2,576.41 / $4,185.63
| Professional | | $2,018.18 | $2,576.41 | $4,185.63 |