- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.39 / $1,424.31 / $7,634.54
| Professional | | $1,198.39 | $1,424.31 | $7,634.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,230.44 / $2,230.44 / $2,230.44
| Facility | | $2,230.44 | $2,230.44 | $2,230.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.28 / $2,230.44 / $2,516.57
| Professional | | $1,160.28 | $2,230.44 | $2,516.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,105.76 / $1,520.42 / $2,230.44
| Facility | | $1,105.76 | $1,520.42 | $2,230.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.99 / $2,230.44 / $2,942.80
| Professional | | $1,359.99 | $2,230.44 | $2,942.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.28 / $2,350.67 / $2,639.36
| Professional | | $1,938.28 | $2,350.67 | $2,639.36 |