- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.67 / $2,148.37 / $8,066.50
| Professional | | $1,642.67 | $2,148.37 | $8,066.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,440.23 / $2,440.23 / $2,440.23
| Facility | | $2,440.23 | $2,440.23 | $2,440.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.33 / $2,440.23 / $2,616.09
| Professional | | $1,298.33 | $2,440.23 | $2,616.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.34 / $1,661.48 / $2,440.23
| Facility | | $1,208.34 | $1,661.48 | $2,440.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.42 / $2,440.23 / $3,196.90
| Professional | | $1,477.42 | $2,440.23 | $3,196.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,086.92 / $2,550.17 / $2,863.36
| Professional | | $2,086.92 | $2,550.17 | $2,863.36 |