- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.12 / $1,968.09 / $7,416.46
| Professional | | $1,489.12 | $1,968.09 | $7,416.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.92 / $2,219.92 / $2,219.92
| Facility | | $2,219.92 | $2,219.92 | $2,219.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.85 / $2,114.98 / $2,219.92
| Professional | | $1,152.85 | $2,114.98 | $2,219.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,100.51 / $1,417.07 / $2,219.92
| Facility | | $1,100.51 | $1,417.07 | $2,219.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.41 / $2,114.98 / $2,913.40
| Professional | | $1,346.41 | $2,114.98 | $2,913.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.18 / $2,229.75 / $2,583.98
| Professional | | $1,916.18 | $2,229.75 | $2,583.98 |