- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.79 / $1,873.92 / $7,024.44
| Professional | | $1,429.79 | $1,873.92 | $7,024.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,127.39 / $2,127.39 / $2,127.39
| Facility | | $2,127.39 | $2,127.39 | $2,127.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.24 / $2,127.39 / $2,275.62
| Professional | | $803.24 | $2,127.39 | $2,275.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $853.91 / $1,056.59 / $2,127.39
| Facility | | $853.91 | $1,056.59 | $2,127.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.73 / $2,127.39 / $2,783.90
| Professional | | $1,231.73 | $2,127.39 | $2,783.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.66 / $2,179.52 / $2,466.75
| Professional | | $1,842.66 | $2,179.52 | $2,466.75 |