- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.06 / $1,988.02 / $7,233.55
| Professional | | $1,493.06 | $1,988.02 | $7,233.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,203.10 / $2,203.10 / $2,203.10
| Facility | | $2,203.10 | $2,203.10 | $2,203.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.10 / $2,203.10 / $2,276.19
| Professional | | $1,139.10 | $2,203.10 | $2,276.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.98 / $1,486.34 / $2,203.10
| Facility | | $1,080.98 | $1,486.34 | $2,203.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.88 / $2,203.10 / $2,927.40
| Professional | | $1,352.88 | $2,203.10 | $2,927.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.67 / $2,218.16 / $2,515.91
| Professional | | $1,861.67 | $2,218.16 | $2,515.91 |