- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,696.53 / $2,297.31 / $8,591.54
| Professional | | $1,696.53 | $2,297.31 | $8,591.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,520.16 / $2,520.16 / $2,520.16
| Facility | | $2,520.16 | $2,520.16 | $2,520.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.77 / $2,520.16 / $2,632.39
| Professional | | $1,314.77 | $2,520.16 | $2,632.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.42 / $1,713.83 / $2,520.16
| Facility | | $1,246.42 | $1,713.83 | $2,520.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.54 / $2,520.16 / $3,331.30
| Professional | | $1,539.54 | $2,520.16 | $3,331.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.82 / $2,672.72 / $3,384.48
| Professional | | $2,203.82 | $2,672.72 | $3,384.48 |