- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.24 / $1,251.75 / $6,603.58
| Professional | | $1,054.24 | $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
- $1,195.46 / $2,020.12 / $3,592.14
| Professional | | $1,195.46 | $2,020.12 | $3,592.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,245.77 / $1,763.79 / $2,296.61
| Facility | | $1,245.77 | $1,763.79 | $2,296.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.01 / $2,062.44 / $3,436.76
| Professional | | $1,267.01 | $2,062.44 | $3,436.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.47 / $2,164.50 / $3,538.13
| Professional | | $1,790.47 | $2,164.50 | $3,538.13 |