- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.58 / $1,328.09 / $7,006.81
| Professional | | $1,112.58 | $1,328.09 | $7,006.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.94 / $2,138.94 / $2,138.94
| Facility | | $2,138.94 | $2,138.94 | $2,138.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.77 / $2,138.94 / $3,844.99
| Professional | | $1,254.77 | $2,138.94 | $3,844.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.00 / $1,734.13 / $2,431.33
| Facility | | $1,318.00 | $1,734.13 | $2,431.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.32 / $2,187.00 / $3,644.32
| Professional | | $1,341.32 | $2,187.00 | $3,644.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.84 / $2,249.59 / $2,854.68
| Professional | | $1,858.84 | $2,249.59 | $2,854.68 |