- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.98 / $1,327.83 / $7,002.03
| Professional | | $1,129.98 | $1,327.83 | $7,002.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,143.16 / $2,143.16 / $2,143.16
| Facility | | $2,143.16 | $2,143.16 | $2,143.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.76 / $2,143.16 / $3,814.98
| Professional | | $1,270.76 | $2,143.16 | $3,814.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,322.11 / $1,772.43 / $2,430.69
| Facility | | $1,322.11 | $1,772.43 | $2,430.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.91 / $2,188.61 / $3,647.01
| Professional | | $1,335.91 | $2,188.61 | $3,647.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.13 / $2,218.71 / $2,773.40
| Professional | | $1,862.13 | $2,218.71 | $2,773.40 |