- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.51 / $1,949.92 / $7,247.39
| Professional | | $1,474.51 | $1,949.92 | $7,247.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,199.94 / $2,199.94 / $2,199.94
| Facility | | $2,199.94 | $2,199.94 | $2,199.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.38 / $2,199.94 / $2,331.48
| Professional | | $1,358.38 | $2,199.94 | $2,331.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,083.26 / $1,489.49 / $2,199.94
| Facility | | $1,083.26 | $1,489.49 | $2,199.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.26 / $2,199.94 / $2,900.10
| Professional | | $1,340.26 | $2,199.94 | $2,900.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.16 / $2,321.73 / $2,658.48
| Professional | | $2,023.16 | $2,321.73 | $2,658.48 |