- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.96 / $1,251.75 / $6,603.58
| Professional | | $1,053.96 | $1,251.75 | $6,603.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,020.12 / $2,020.12 / $2,020.12
| Facility | | $2,020.12 | $2,020.12 | $2,020.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.10 / $2,020.12 / $3,609.06
| Professional | | $1,195.10 | $2,020.12 | $3,609.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.77 / $1,763.83 / $2,296.61
| Facility | | $1,245.77 | $1,763.83 | $2,296.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.22 / $2,062.44 / $3,436.76
| Professional | | $1,258.22 | $2,062.44 | $3,436.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.15 / $2,129.92 / $2,795.38
| Professional | | $1,752.15 | $2,129.92 | $2,795.38 |