- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.31 / $1,655.64 / $7,446.25
| Professional | | $1,471.31 | $1,655.64 | $7,446.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,208.89 / $2,208.89 / $2,208.89
| Facility | | $2,208.89 | $2,208.89 | $2,208.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.38 / $2,208.89 / $2,366.98
| Professional | | $1,690.38 | $2,208.89 | $2,366.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.26 / $2,674.10 / $3,044.86
| Facility | | $1,091.26 | $2,674.10 | $3,044.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.73 / $2,003.80 / $2,890.30
| Professional | | $1,335.73 | $2,003.80 | $2,890.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,922.77 / $2,454.61 / $3,844.29
| Professional | | $1,922.77 | $2,454.61 | $3,844.29 |