- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.10 / $1,171.64 / $2,070.50
| Professional | | $1,007.10 | $1,171.64 | $2,070.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,005.93 / $2,005.93 / $2,005.93
| Facility | | $2,005.93 | $2,005.93 | $2,005.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.48 / $2,005.93 / $3,371.40
| Professional | | $1,145.48 | $2,005.93 | $3,371.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,221.03 / $1,625.00 / $2,201.73
| Facility | | $1,221.03 | $1,625.00 | $2,201.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.71 / $2,052.19 / $3,419.69
| Professional | | $1,248.71 | $2,052.19 | $3,419.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.64 / $2,061.44 / $2,770.63
| Professional | | $1,736.64 | $2,061.44 | $2,770.63 |