- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.26 / $1,698.49 / $6,354.73
| Professional | | $1,293.26 | $1,698.49 | $6,354.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,932.32 / $1,932.32 / $1,932.32
| Facility | | $1,932.32 | $1,932.32 | $1,932.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.03 / $1,932.32 / $2,052.71
| Professional | | $1,019.03 | $1,932.32 | $2,052.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.74 / $1,315.51 / $1,932.32
| Facility | | $956.74 | $1,315.51 | $1,932.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.25 / $1,932.32 / $2,521.40
| Professional | | $1,165.25 | $1,932.32 | $2,521.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.64 / $1,981.33 / $2,247.67
| Professional | | $1,650.64 | $1,981.33 | $2,247.67 |