- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.91 / $1,912.27 / $7,455.11
| Professional | | $1,414.91 | $1,912.27 | $7,455.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.10 / $2,254.10 / $2,254.10
| Facility | | $2,254.10 | $2,254.10 | $2,254.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.09 / $2,254.10 / $2,733.65
| Professional | | $1,315.09 | $2,254.10 | $2,733.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.33 / $1,533.59 / $2,254.10
| Facility | | $1,115.33 | $1,533.59 | $2,254.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.11 / $2,254.10 / $2,958.20
| Professional | | $1,367.11 | $2,254.10 | $2,958.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.98 / $2,401.78 / $2,650.23
| Professional | | $2,089.98 | $2,401.78 | $2,650.23 |