- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.53 / $1,951.24 / $7,311.69
| Professional | | $1,394.53 | $1,951.24 | $7,311.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.31 / $2,095.31 / $2,095.31
| Facility | | $2,095.31 | $2,095.31 | $2,095.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.23 / $2,095.31 / $2,209.27
| Professional | | $1,171.23 | $2,095.31 | $2,209.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.08 / $1,424.61 / $2,095.31
| Facility | | $1,036.08 | $1,424.61 | $2,095.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.41 / $2,095.31 / $2,814.70
| Professional | | $1,280.41 | $2,095.31 | $2,814.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.72 / $2,239.87 / $2,514.55
| Professional | | $1,872.72 | $2,239.87 | $2,514.55 |