- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.15 / $1,252.08 / $6,612.94
| Professional | | $1,031.15 | $1,252.08 | $6,612.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,043.26 / $2,043.26 / $2,043.26
| Facility | | $2,043.26 | $2,043.26 | $2,043.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.67 / $2,043.26 / $3,558.60
| Professional | | $1,134.67 | $2,043.26 | $3,558.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,011.56 / $1,639.02 / $2,273.21
| Facility | | $1,011.56 | $1,639.02 | $2,273.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.65 / $2,068.91 / $3,447.54
| Professional | | $1,267.65 | $2,068.91 | $3,447.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.11 / $2,094.71 / $2,680.02
| Professional | | $1,745.11 | $2,094.71 | $2,680.02 |