- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.31 / $1,789.67 / $6,928.38
| Professional | | $1,409.31 | $1,789.67 | $6,928.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,222.56 / $2,222.56 / $2,222.56
| Facility | | $2,222.56 | $2,222.56 | $2,222.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.96 / $2,222.56 / $2,381.54
| Professional | | $1,039.96 | $2,222.56 | $2,381.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.60 / $1,506.46 / $2,177.07
| Facility | | $1,095.60 | $1,506.46 | $2,177.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.20 / $2,218.81 / $2,880.50
| Professional | | $1,331.20 | $2,218.81 | $2,880.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,780.02 / $2,227.11 / $2,545.27
| Professional | | $1,780.02 | $2,227.11 | $2,545.27 |