- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.51 / $1,907.74 / $9,184.66
| Professional | | $1,623.51 | $1,907.74 | $9,184.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,796.73 / $2,796.73 / $2,796.73
| Facility | | $2,796.73 | $2,796.73 | $2,796.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.40 / $2,796.73 / $2,796.73
| Professional | | $2,101.40 | $2,796.73 | $2,796.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,796.73 / $3,322.80 / $3,445.86
| Facility | | $2,796.73 | $3,322.80 | $3,445.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.70 / $2,422.12 / $3,699.50
| Professional | | $1,709.70 | $2,422.12 | $3,699.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.12 / $3,126.01 / $4,895.09
| Professional | | $2,607.12 | $3,126.01 | $4,895.09 |