- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.07 / $1,792.34 / $6,698.70
| Professional | | $1,365.07 | $1,792.34 | $6,698.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,037.48 / $2,037.48 / $2,037.48
| Facility | | $2,037.48 | $2,037.48 | $2,037.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.97 / $2,037.48 / $2,159.80
| Professional | | $1,066.97 | $2,037.48 | $2,159.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.88 / $1,314.52 / $2,037.48
| Facility | | $1,008.88 | $1,314.52 | $2,037.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.95 / $2,037.48 / $2,661.40
| Professional | | $1,229.95 | $2,037.48 | $2,661.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,740.41 / $2,110.71 / $2,369.92
| Professional | | $1,740.41 | $2,110.71 | $2,369.92 |