- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.64 / $1,339.78 / $7,067.72
| Professional | | $1,125.64 | $1,339.78 | $7,067.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,156.83 / $2,156.83 / $2,156.83
| Facility | | $2,156.83 | $2,156.83 | $2,156.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.65 / $2,156.83 / $3,840.48
| Professional | | $1,265.65 | $2,156.83 | $3,840.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.99 / $1,786.74 / $2,456.00
| Facility | | $1,327.99 | $1,786.74 | $2,456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.94 / $2,205.87 / $3,675.76
| Professional | | $1,352.94 | $2,205.87 | $3,675.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.77 / $2,275.19 / $2,950.65
| Professional | | $1,875.77 | $2,275.19 | $2,950.65 |