- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.22 / $1,647.60 / $6,295.82
| Professional | | $1,391.22 | $1,647.60 | $6,295.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.23 / $2,073.23 / $2,073.23
| Facility | | $2,073.23 | $2,073.23 | $2,073.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.70 / $2,017.21 / $2,073.23
| Professional | | $1,059.70 | $2,017.21 | $2,073.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.40 / $1,412.18 / $2,073.23
| Facility | | $1,027.40 | $1,412.18 | $2,073.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.44 / $2,017.21 / $2,720.90
| Professional | | $1,257.44 | $2,017.21 | $2,720.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.22 / $2,030.58 / $2,309.98
| Professional | | $1,719.22 | $2,030.58 | $2,309.98 |