- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.45 / $2,031.96 / $7,417.86
| Professional | | $1,539.45 | $2,031.96 | $7,417.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,274.61 / $2,274.61 / $2,274.61
| Facility | | $2,274.61 | $2,274.61 | $2,274.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.31 / $2,274.61 / $2,340.21
| Professional | | $1,058.31 | $2,274.61 | $2,340.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,118.58 / $1,534.63 / $2,274.61
| Facility | | $1,118.58 | $1,534.63 | $2,274.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.34 / $2,274.61 / $3,012.80
| Professional | | $1,392.34 | $2,274.61 | $3,012.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.65 / $2,202.12 / $2,584.62
| Professional | | $1,916.65 | $2,202.12 | $2,584.62 |