- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.91 / $1,244.91 / $6,568.62
| Professional | | $1,059.91 | $1,244.91 | $6,568.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,003.82 / $2,003.82 / $2,003.82
| Facility | | $2,003.82 | $2,003.82 | $2,003.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.86 / $2,003.82 / $3,548.47
| Professional | | $1,176.86 | $2,003.82 | $3,548.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.83 / $1,659.22 / $2,305.46
| Facility | | $1,234.83 | $1,659.22 | $2,305.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.16 / $2,050.04 / $3,416.10
| Professional | | $1,256.16 | $2,050.04 | $3,416.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.28 / $2,145.28 / $2,675.68
| Professional | | $1,742.28 | $2,145.28 | $2,675.68 |