- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.32 / $1,100.39 / $1,925.27
| Professional | | $1,028.32 | $1,100.39 | $1,925.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,010.66 / $2,010.66 / $2,010.66
| Facility | | $2,010.66 | $2,010.66 | $2,010.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.17 / $2,010.66 / $2,119.06
| Professional | | $1,256.17 | $2,010.66 | $2,119.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $990.42 / $2,089.75 / $2,253.60
| Facility | | $990.42 | $2,089.75 | $2,253.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.04 / $1,807.74 / $2,607.50
| Professional | | $1,205.04 | $1,807.74 | $2,607.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.65 / $1,957.20 / $3,502.97
| Professional | | $1,639.65 | $1,957.20 | $3,502.97 |