- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.54 / $1,870.19 / $8,825.31
| Professional | | $1,563.54 | $1,870.19 | $8,825.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,657.92 / $2,657.92 / $2,657.92
| Facility | | $2,657.92 | $2,657.92 | $2,657.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.87 / $2,657.92 / $2,657.92
| Professional | | $2,001.87 | $2,657.92 | $2,657.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,303.70 / $1,629.63 / $2,657.92
| Facility | | $1,303.70 | $1,629.63 | $2,657.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.91 / $2,439.12 / $3,518.20
| Professional | | $1,625.91 | $2,439.12 | $3,518.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.41 / $2,871.60 / $4,683.27
| Professional | | $2,290.41 | $2,871.60 | $4,683.27 |