- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.22 / $1,930.19 / $7,231.81
| Professional | | $1,475.22 | $1,930.19 | $7,231.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,192.06 / $2,192.06 / $2,192.06
| Facility | | $2,192.06 | $2,192.06 | $2,192.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.15 / $2,192.06 / $2,336.73
| Professional | | $1,147.15 | $2,192.06 | $2,336.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,084.94 / $1,491.80 / $2,192.06
| Facility | | $1,084.94 | $1,491.80 | $2,192.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.32 / $2,192.06 / $2,872.10
| Professional | | $1,327.32 | $2,192.06 | $2,872.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.22 / $2,264.31 / $2,641.32
| Professional | | $1,884.22 | $2,264.31 | $2,641.32 |