- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.83 / $1,288.13 / $6,796.55
| Professional | | $1,076.83 | $1,288.13 | $6,796.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.76 / $2,073.76 / $2,073.76
| Facility | | $2,073.76 | $2,073.76 | $2,073.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.65 / $2,073.76 / $3,680.95
| Professional | | $1,216.65 | $2,073.76 | $3,680.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.40 / $1,715.70 / $2,352.27
| Facility | | $1,277.40 | $1,715.70 | $2,352.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.66 / $2,121.21 / $3,534.70
| Professional | | $1,300.66 | $2,121.21 | $3,534.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.45 / $2,209.35 / $3,632.47
| Professional | | $1,802.45 | $2,209.35 | $3,632.47 |