- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.29 / $6,379.23 / $6,379.23
| Professional | | $1,299.29 | $6,379.23 | $6,379.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,046.41 / $2,046.41 / $2,046.41
| Facility | | $2,046.41 | $2,046.41 | $2,046.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.64 / $2,046.41 / $2,197.05
| Professional | | $1,255.64 | $2,046.41 | $2,197.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.93 / $2,132.65 / $2,297.23
| Facility | | $1,007.93 | $2,132.65 | $2,297.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.39 / $1,839.77 / $2,653.70
| Professional | | $1,226.39 | $1,839.77 | $2,653.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.01 / $2,132.65 / $3,564.94
| Professional | | $1,723.01 | $2,132.65 | $3,564.94 |