- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.57 / $1,348.36 / $7,109.90
| Professional | | $1,152.57 | $1,348.36 | $7,109.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,177.86 / $2,177.86 / $2,177.86
| Facility | | $2,177.86 | $2,177.86 | $2,177.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.19 / $2,177.86 / $3,886.67
| Professional | | $1,293.19 | $2,177.86 | $3,886.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.74 / $1,824.50 / $2,499.01
| Facility | | $1,342.74 | $1,824.50 | $2,499.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.59 / $2,222.04 / $3,702.72
| Professional | | $1,362.59 | $2,222.04 | $3,702.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.80 / $2,257.19 / $2,816.10
| Professional | | $1,890.80 | $2,257.19 | $2,816.10 |