- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.74 / $2,044.95 / $7,678.16
| Professional | | $1,564.74 | $2,044.95 | $7,678.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,320.88 / $2,320.88 / $2,320.88
| Facility | | $2,320.88 | $2,320.88 | $2,320.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.41 / $2,320.88 / $2,489.80
| Professional | | $1,126.41 | $2,320.88 | $2,489.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.70 / $1,259.83 / $2,320.88
| Facility | | $1,148.70 | $1,259.83 | $2,320.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.76 / $2,320.88 / $3,044.30
| Professional | | $1,341.76 | $2,320.88 | $3,044.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.73 / $2,427.63 / $2,725.76
| Professional | | $2,001.73 | $2,427.63 | $2,725.76 |