- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.58 / $1,355.64 / $7,186.19
| Professional | | $1,266.58 | $1,355.64 | $7,186.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,192.06 / $2,192.06 / $2,192.06
| Facility | | $2,192.06 | $2,192.06 | $2,192.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.95 / $2,192.06 / $2,192.06
| Professional | | $1,626.95 | $2,192.06 | $2,192.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,192.06 / $2,590.90 / $2,691.92
| Facility | | $2,192.06 | $2,590.90 | $2,691.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.64 / $1,896.45 / $2,896.60
| Professional | | $1,338.64 | $1,896.45 | $2,896.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.86 / $2,440.19 / $3,834.11
| Professional | | $2,032.86 | $2,440.19 | $3,834.11 |