- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.00 / $1,309.91 / $6,550.64
| Professional | | $1,102.00 | $1,309.91 | $6,550.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,958.08 / $1,958.08 / $1,958.08
| Facility | | $1,958.08 | $1,958.08 | $1,958.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.08 / $1,958.08 / $1,997.42
| Professional | | $1,000.08 | $1,958.08 | $1,997.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $970.89 / $1,317.78 / $1,958.08
| Facility | | $970.89 | $1,317.78 | $1,958.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.98 / $1,958.08 / $2,564.10
| Professional | | $1,184.98 | $1,958.08 | $2,564.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.05 / $2,014.87 / $2,284.91
| Professional | | $1,691.05 | $2,014.87 | $2,284.91 |