- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.46 / $1,319.30 / $6,948.10
| Professional | | $1,107.46 | $1,319.30 | $6,948.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.81 / $2,125.81 / $2,125.81
| Facility | | $2,125.81 | $2,125.81 | $2,125.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.59 / $2,125.81 / $3,786.88
| Professional | | $1,244.59 | $2,125.81 | $3,786.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,256.17 / $1,721.75 / $2,412.98
| Facility | | $1,256.17 | $1,721.75 | $2,412.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.31 / $2,170.28 / $3,616.46
| Professional | | $1,330.31 | $2,170.28 | $3,616.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.15 / $2,235.52 / $2,835.20
| Professional | | $1,846.15 | $2,235.52 | $2,835.20 |