- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.11 / $1,696.50 / $6,606.12
| Professional | | $1,254.11 | $1,696.50 | $6,606.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,998.57 / $1,998.57 / $1,998.57
| Facility | | $1,998.57 | $1,998.57 | $1,998.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.43 / $1,998.57 / $2,126.05
| Professional | | $1,104.43 | $1,998.57 | $2,126.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $989.10 / $1,360.01 / $1,998.57
| Facility | | $989.10 | $1,360.01 | $1,998.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.15 / $1,998.57 / $2,622.90
| Professional | | $1,212.15 | $1,998.57 | $2,622.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.96 / $2,090.76 / $2,420.88
| Professional | | $1,723.96 | $2,090.76 | $2,420.88 |