- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.67 / $1,281.38 / $6,757.41
| Professional | | $1,081.67 | $1,281.38 | $6,757.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.13 / $2,071.13 / $2,071.13
| Facility | | $2,071.13 | $2,071.13 | $2,071.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.91 / $2,071.13 / $3,714.84
| Professional | | $1,210.91 | $2,071.13 | $3,714.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.60 / $1,708.25 / $2,356.06
| Facility | | $1,277.60 | $1,708.25 | $2,356.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.36 / $2,113.12 / $3,521.22
| Professional | | $1,294.36 | $2,113.12 | $3,521.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.81 / $2,183.03 / $2,676.11
| Professional | | $1,796.81 | $2,183.03 | $2,676.11 |