- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.01 / $1,950.15 / $7,305.21
| Professional | | $1,491.01 | $1,950.15 | $7,305.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.62 / $2,213.62 / $2,213.62
| Facility | | $2,213.62 | $2,213.62 | $2,213.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.48 / $2,213.62 / $2,361.76
| Professional | | $1,168.48 | $2,213.62 | $2,361.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.51 / $1,506.33 / $2,213.62
| Facility | | $1,095.51 | $1,506.33 | $2,213.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.23 / $2,213.62 / $2,902.20
| Professional | | $1,341.23 | $2,213.62 | $2,902.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.96 / $2,309.07 / $2,712.60
| Professional | | $1,903.96 | $2,309.07 | $2,712.60 |