- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.65 / $1,774.56 / $6,642.03
| Professional | | $1,355.65 | $1,774.56 | $6,642.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,014.34 / $2,014.34 / $2,014.34
| Facility | | $2,014.34 | $2,014.34 | $2,014.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.36 / $2,014.34 / $2,140.01
| Professional | | $1,064.36 | $2,014.34 | $2,140.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $996.40 / $1,370.05 / $2,014.34
| Facility | | $996.40 | $1,370.05 | $2,014.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.92 / $2,014.34 / $2,639.70
| Professional | | $1,219.92 | $2,014.34 | $2,639.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.07 / $2,098.17 / $2,355.84
| Professional | | $1,730.07 | $2,098.17 | $2,355.84 |