- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.29 / $1,275.88 / $6,668.07
| Professional | | $1,147.29 | $1,275.88 | $6,668.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.10 / $2,040.10 / $2,040.10
| Facility | | $2,040.10 | $2,040.10 | $2,040.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.68 / $2,039.57 / $3,724.61
| Professional | | $1,255.68 | $2,039.57 | $3,724.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,256.41 / $1,813.35 / $2,452.84
| Facility | | $1,256.41 | $1,813.35 | $2,452.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.81 / $2,073.76 / $3,455.63
| Professional | | $1,324.81 | $2,073.76 | $3,455.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.18 / $2,183.11 / $2,716.82
| Professional | | $1,808.18 | $2,183.11 | $2,716.82 |