- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.49 / $1,311.13 / $6,852.28
| Professional | | $1,190.49 | $1,311.13 | $6,852.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,091.11 / $2,091.11 / $2,091.11
| Facility | | $2,091.11 | $2,091.11 | $2,091.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.02 / $2,083.78 / $3,845.43
| Professional | | $1,287.02 | $2,083.78 | $3,845.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,287.90 / $1,842.32 / $2,543.28
| Facility | | $1,287.90 | $1,842.32 | $2,543.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.67 / $2,128.76 / $3,547.28
| Professional | | $1,344.67 | $2,128.76 | $3,547.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.38 / $2,248.07 / $2,797.66
| Professional | | $1,853.38 | $2,248.07 | $2,797.66 |