- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.71 / $1,140.53 / $2,109.40
| Professional | | $1,058.71 | $1,140.53 | $2,109.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.62 / $2,213.62 / $2,213.62
| Facility | | $2,213.62 | $2,213.62 | $2,213.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.12 / $2,213.62 / $2,387.94
| Professional | | $889.12 | $2,213.62 | $2,387.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.82 / $2,213.62 / $2,356.69
| Facility | | $1,089.82 | $2,213.62 | $2,356.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.64 / $1,991.67 / $2,872.80
| Professional | | $1,327.64 | $1,991.67 | $2,872.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.60 / $2,308.40 / $3,855.40
| Professional | | $1,870.60 | $2,308.40 | $3,855.40 |