- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.38 / $1,342.75 / $6,747.35
| Professional | | $1,153.38 | $1,342.75 | $6,747.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,064.82 / $2,064.82 / $2,064.82
| Facility | | $2,064.82 | $2,064.82 | $2,064.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.31 / $2,064.82 / $3,659.63
| Professional | | $1,287.31 | $2,064.82 | $3,659.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.90 / $1,708.13 / $2,454.73
| Facility | | $1,271.90 | $1,708.13 | $2,454.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.80 / $2,098.03 / $3,496.06
| Professional | | $1,363.80 | $2,098.03 | $3,496.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.28 / $2,246.13 / $3,011.25
| Professional | | $1,850.28 | $2,246.13 | $3,011.25 |