- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.82 / $1,254.75 / $6,617.42
| Professional | | $1,053.82 | $1,254.75 | $6,617.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,029.06 / $2,029.06 / $2,029.06
| Facility | | $2,029.06 | $2,029.06 | $2,029.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.97 / $2,029.06 / $3,631.41
| Professional | | $1,184.97 | $2,029.06 | $3,631.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,251.20 / $1,679.37 / $2,299.77
| Facility | | $1,251.20 | $1,679.37 | $2,299.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.73 / $2,070.53 / $3,450.24
| Professional | | $1,266.73 | $2,070.53 | $3,450.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.73 / $2,125.44 / $2,700.94
| Professional | | $1,758.73 | $2,125.44 | $2,700.94 |