- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.06 / $1,786.84 / $6,732.16
| Professional | | $1,352.06 | $1,786.84 | $6,732.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,012.76 / $2,012.76 / $2,012.76
| Facility | | $2,012.76 | $2,012.76 | $2,012.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.66 / $1,943.30 / $2,012.76
| Professional | | $1,017.66 | $1,943.30 | $2,012.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $997.18 / $1,371.12 / $2,012.76
| Facility | | $997.18 | $1,371.12 | $2,012.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.18 / $1,943.30 / $2,644.60
| Professional | | $1,222.18 | $1,943.30 | $2,644.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.41 / $2,073.67 / $2,346.96
| Professional | | $1,740.41 | $2,073.67 | $2,346.96 |