- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.26 / $1,300.49 / $6,884.75
| Professional | | $1,182.26 | $1,300.49 | $6,884.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,101.10 / $2,101.10 / $2,101.10
| Facility | | $2,101.10 | $2,101.10 | $2,101.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.54 / $2,101.10 / $3,774.32
| Professional | | $1,232.54 | $2,101.10 | $3,774.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.80 / $1,706.91 / $2,385.79
| Facility | | $1,294.80 | $1,706.91 | $2,385.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.59 / $2,147.63 / $3,578.73
| Professional | | $1,317.59 | $2,147.63 | $3,578.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.41 / $2,207.36 / $2,804.88
| Professional | | $1,826.41 | $2,207.36 | $2,804.88 |