- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.48 / $2,254.29 / $8,500.20
| Professional | | $1,644.48 | $2,254.29 | $8,500.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,475.98 / $2,475.98 / $2,475.98
| Facility | | $2,475.98 | $2,475.98 | $2,475.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.31 / $2,475.98 / $2,559.05
| Professional | | $1,415.31 | $2,475.98 | $2,559.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.25 / $1,687.47 / $2,475.98
| Facility | | $1,227.25 | $1,687.47 | $2,475.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.86 / $2,475.98 / $3,260.60
| Professional | | $1,506.86 | $2,475.98 | $3,260.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,199.63 / $2,630.88 / $2,911.04
| Professional | | $2,199.63 | $2,630.88 | $2,911.04 |