- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.75 / $1,286.89 / $6,754.32
| Professional | | $1,085.75 | $1,286.89 | $6,754.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,061.14 / $2,061.14 / $2,061.14
| Facility | | $2,061.14 | $2,061.14 | $2,061.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.45 / $2,061.14 / $3,702.44
| Professional | | $1,220.45 | $2,061.14 | $3,702.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.78 / $1,715.01 / $2,339.62
| Facility | | $1,270.78 | $1,715.01 | $2,339.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.25 / $2,107.73 / $3,512.24
| Professional | | $1,295.25 | $2,107.73 | $3,512.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,797.28 / $2,189.42 / $2,760.14
| Professional | | $1,797.28 | $2,189.42 | $2,760.14 |