- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.66 / $1,342.20 / $7,050.44
| Professional | | $1,129.66 | $1,342.20 | $7,050.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,176.81 / $2,176.81 / $2,176.81
| Facility | | $2,176.81 | $2,176.81 | $2,176.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.59 / $2,176.81 / $3,881.94
| Professional | | $1,273.59 | $2,176.81 | $3,881.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.34 / $1,775.03 / $2,458.53
| Facility | | $1,182.34 | $1,775.03 | $2,458.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.97 / $2,198.32 / $3,663.18
| Professional | | $1,359.97 | $2,198.32 | $3,663.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.65 / $2,285.44 / $2,982.83
| Professional | | $1,869.65 | $2,285.44 | $2,982.83 |