- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.84 / $1,684.11 / $8,265.20
| Professional | | $1,309.84 | $1,684.11 | $8,265.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,498.08 / $2,498.08 / $2,498.08
| Facility | | $2,498.08 | $2,498.08 | $2,498.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.05 / $2,498.08 / $2,681.27
| Professional | | $1,318.05 | $2,498.08 | $2,681.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,236.46 / $1,554.96 / $2,498.08
| Facility | | $1,236.46 | $1,554.96 | $2,498.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.98 / $2,498.08 / $3,276.00
| Professional | | $1,513.98 | $2,498.08 | $3,276.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,156.35 / $2,612.31 / $2,936.31
| Professional | | $2,156.35 | $2,612.31 | $2,936.31 |