- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.03 / $1,859.28 / $7,177.62
| Professional | | $1,463.03 | $1,859.28 | $7,177.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,307.21 / $2,307.21 / $2,307.21
| Facility | | $2,307.21 | $2,307.21 | $2,307.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.08 / $2,307.21 / $2,412.96
| Professional | | $1,214.08 | $2,307.21 | $2,412.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.41 / $1,498.52 / $2,307.21
| Facility | | $1,137.41 | $1,498.52 | $2,307.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.96 / $2,305.08 / $2,992.50
| Professional | | $1,382.96 | $2,305.08 | $2,992.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.10 / $2,304.96 / $2,608.71
| Professional | | $1,954.10 | $2,304.96 | $2,608.71 |