- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.89 / $1,812.08 / $6,779.47
| Professional | | $1,383.89 | $1,812.08 | $6,779.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,057.46 / $2,057.46 / $2,057.46
| Facility | | $2,057.46 | $2,057.46 | $2,057.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.21 / $2,057.46 / $2,188.32
| Professional | | $1,081.21 | $2,057.46 | $2,188.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.85 / $1,399.54 / $2,057.46
| Facility | | $1,017.85 | $1,399.54 | $2,057.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.48 / $2,057.46 / $2,695.00
| Professional | | $1,245.48 | $2,057.46 | $2,695.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.03 / $2,140.92 / $2,403.84
| Professional | | $1,735.03 | $2,140.92 | $2,403.84 |