- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.10 / $1,711.01 / $7,841.16
| Professional | | $1,395.10 | $1,711.01 | $7,841.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,382.40 / $2,382.40 / $2,382.40
| Facility | | $2,382.40 | $2,382.40 | $2,382.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.48 / $2,382.40 / $2,382.40
| Professional | | $1,754.48 | $2,382.40 | $2,382.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,382.40 / $2,868.45 / $2,962.63
| Facility | | $2,382.40 | $2,868.45 | $2,962.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.99 / $2,066.92 / $3,157.00
| Professional | | $1,458.99 | $2,066.92 | $3,157.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250.63 / $2,761.48 / $4,173.59
| Professional | | $2,250.63 | $2,761.48 | $4,173.59 |