- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,749.26 / $2,284.42 / $8,584.71
| Professional | | $1,749.26 | $2,284.42 | $8,584.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,593.77 / $2,593.77 / $2,593.77
| Facility | | $2,593.77 | $2,593.77 | $2,593.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.24 / $2,593.77 / $2,786.03
| Professional | | $1,386.24 | $2,593.77 | $2,786.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,283.43 / $1,764.72 / $2,593.77
| Facility | | $1,283.43 | $1,764.72 | $2,593.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.21 / $2,593.77 / $3,402.00
| Professional | | $1,572.21 | $2,593.77 | $3,402.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.17 / $2,679.68 / $3,021.31
| Professional | | $2,431.17 | $2,679.68 | $3,021.31 |