- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.41 / $1,804.86 / $6,762.54
| Professional | | $1,377.41 | $1,804.86 | $6,762.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.09 / $2,050.09 / $2,050.09
| Facility | | $2,050.09 | $2,050.09 | $2,050.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.83 / $2,050.09 / $2,187.73
| Professional | | $1,083.83 | $2,050.09 | $2,187.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.75 / $1,395.28 / $2,050.09
| Facility | | $1,014.75 | $1,395.28 | $2,050.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.65 / $2,050.09 / $2,682.40
| Professional | | $1,239.65 | $2,050.09 | $2,682.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.92 / $2,100.00 / $3,221.57
| Professional | | $1,729.92 | $2,100.00 | $3,221.57 |