- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.75 / $1,115.13 / $5,749.61
| Professional | | $1,016.75 | $1,115.13 | $5,749.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.23 / $1,747.23 / $1,747.23
| Facility | | $1,747.23 | $1,747.23 | $1,747.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.73 / $1,747.23 / $3,243.41
| Professional | | $1,091.73 | $1,747.23 | $3,243.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,025.02 / $1,613.81 / $2,223.23
| Facility | | $1,025.02 | $1,613.81 | $2,223.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.20 / $1,785.83 / $2,975.83
| Professional | | $1,153.20 | $1,785.83 | $2,975.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,374.44 / $1,374.44 / $1,374.44
| Facility | | $1,374.44 | $1,374.44 | $1,374.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.00 / $1,923.40 / $2,444.46
| Professional | | $1,630.00 | $1,923.40 | $2,444.46 |