- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.41 / $1,824.31 / $6,736.55
| Professional | | $1,384.41 | $1,824.31 | $6,736.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,061.14 / $2,061.14 / $2,061.14
| Facility | | $2,061.14 | $2,061.14 | $2,061.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.42 / $2,061.14 / $2,109.75
| Professional | | $1,041.42 | $2,061.14 | $2,109.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.05 / $1,399.82 / $2,061.14
| Facility | | $1,018.05 | $1,399.82 | $2,061.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.33 / $2,061.14 / $2,705.50
| Professional | | $1,250.33 | $2,061.14 | $2,705.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.69 / $2,051.19 / $2,374.39
| Professional | | $1,743.69 | $2,051.19 | $2,374.39 |