- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.96 / $1,334.22 / $6,809.10
| Professional | | $1,123.96 | $1,334.22 | $6,809.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,032.22 / $2,032.22 / $2,032.22
| Facility | | $2,032.22 | $2,032.22 | $2,032.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.77 / $2,032.22 / $3,837.98
| Professional | | $1,264.77 | $2,032.22 | $3,837.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,253.56 / $1,784.71 / $2,459.16
| Facility | | $1,253.56 | $1,784.71 | $2,459.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.00 / $2,052.19 / $3,419.69
| Professional | | $1,334.00 | $2,052.19 | $3,419.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.18 / $2,206.01 / $2,698.78
| Professional | | $1,801.18 | $2,206.01 | $2,698.78 |