- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.80 / $1,325.03 / $5,578.70
| Professional | | $1,071.80 | $1,325.03 | $5,578.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,691.50 / $1,691.50 / $2,010.63
| Facility | | $1,691.50 | $1,691.50 | $2,010.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.82 / $1,691.50 / $2,381.48
| Professional | | $1,051.82 | $1,691.50 | $2,381.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,691.50 / $2,077.40 / $2,125.83
| Facility | | $1,691.50 | $2,077.40 | $2,125.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.20 / $1,466.56 / $2,362.17
| Professional | | $1,035.20 | $1,466.56 | $2,362.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.96 / $1,856.14 / $2,953.53
| Professional | | $1,629.96 | $1,856.14 | $2,953.53 |