- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.31 / $1,365.64 / $7,200.88
| Professional | | $1,174.31 | $1,365.64 | $7,200.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.67 / $2,204.67 / $2,204.67
| Facility | | $2,204.67 | $2,204.67 | $2,204.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.86 / $2,204.67 / $3,967.53
| Professional | | $1,319.86 | $2,204.67 | $3,967.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,359.50 / $1,833.36 / $2,545.81
| Facility | | $1,359.50 | $1,833.36 | $2,545.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.49 / $2,249.54 / $3,748.54
| Professional | | $1,380.49 | $2,249.54 | $3,748.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.24 / $2,373.12 / $2,852.50
| Professional | | $1,915.24 | $2,373.12 | $2,852.50 |