- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.97 / $1,621.81 / $6,031.93
| Professional | | $1,034.97 | $1,621.81 | $6,031.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,938.62 / $1,938.62 / $1,938.62
| Facility | | $1,938.62 | $1,938.62 | $1,938.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.02 / $1,938.62 / $2,064.35
| Professional | | $1,010.02 | $1,938.62 | $2,064.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.06 / $1,195.08 / $1,938.62
| Facility | | $956.06 | $1,195.08 | $1,938.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.17 / $1,932.49 / $2,461.48
| Professional | | $1,143.17 | $1,932.49 | $2,461.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.49 / $1,966.50 / $2,207.98
| Professional | | $1,621.49 | $1,966.50 | $2,207.98 |