- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.55 / $2,135.76 / $8,023.28
| Professional | | $1,633.55 | $2,135.76 | $8,023.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.98 / $2,424.98 / $2,424.98
| Facility | | $2,424.98 | $2,424.98 | $2,424.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.06 / $2,424.98 / $2,603.29
| Professional | | $1,078.06 | $2,424.98 | $2,603.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.22 / $1,344.03 / $2,424.98
| Facility | | $1,134.22 | $1,344.03 | $2,424.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.01 / $2,424.98 / $3,178.70
| Professional | | $1,402.01 | $2,424.98 | $3,178.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.96 / $2,482.98 / $2,848.64
| Professional | | $2,091.96 | $2,482.98 | $2,848.64 |