- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.01 / $1,546.72 / $7,095.75
| Professional | | $1,249.01 | $1,546.72 | $7,095.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,163.67 / $2,163.67 / $2,163.67
| Facility | | $2,163.67 | $2,163.67 | $2,163.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.26 / $2,163.67 / $2,163.67
| Professional | | $1,601.26 | $2,163.67 | $2,163.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,163.67 / $2,558.40 / $2,657.77
| Facility | | $2,163.67 | $2,558.40 | $2,657.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.17 / $1,871.70 / $2,858.80
| Professional | | $1,321.17 | $1,871.70 | $2,858.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.36 / $2,371.21 / $3,783.25
| Professional | | $2,007.36 | $2,371.21 | $3,783.25 |