- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.05 / $1,839.72 / $7,167.27
| Professional | | $1,360.05 | $1,839.72 | $7,167.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,167.35 / $2,167.35 / $2,167.35
| Facility | | $2,167.35 | $2,167.35 | $2,167.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.98 / $1,928.17 / $2,167.35
| Professional | | $1,298.98 | $1,928.17 | $2,167.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.74 / $1,475.01 / $2,167.35
| Facility | | $1,072.74 | $1,475.01 | $2,167.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.38 / $2,037.14 / $2,954.66
| Professional | | $1,314.38 | $2,037.14 | $2,954.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.74 / $2,348.21 / $2,963.39
| Professional | | $1,924.74 | $2,348.21 | $2,963.39 |