- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,669.84 / $2,288.28 / $8,708.92
| Professional | | $1,669.84 | $2,288.28 | $8,708.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,631.63 / $2,631.63 / $2,631.63
| Facility | | $2,631.63 | $2,631.63 | $2,631.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.37 / $2,631.63 / $2,866.93
| Professional | | $1,393.37 | $2,631.63 | $2,866.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.04 / $1,731.18 / $2,631.63
| Facility | | $1,259.04 | $1,731.18 | $2,631.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.54 / $2,548.80 / $3,453.10
| Professional | | $1,556.54 | $2,548.80 | $3,453.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,009.54 / $2,009.54 / $36,780.10
| Facility | | $2,009.54 | $2,009.54 | $36,780.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.11 / $2,713.16 / $3,105.96
| Professional | | $2,097.11 | $2,713.16 | $3,105.96 |