- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.23 / $5,580.00 / $6,902.28
| Professional | | $1,406.23 | $5,580.00 | $6,902.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,210.98 / $2,210.98 / $2,210.98
| Facility | | $2,210.98 | $2,210.98 | $2,210.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.87 / $2,210.98 / $2,380.38
| Professional | | $1,429.87 | $2,210.98 | $2,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.06 / $2,333.50 / $2,505.96
| Facility | | $1,089.06 | $2,333.50 | $2,505.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.35 / $1,989.73 / $2,870.00
| Professional | | $1,326.35 | $1,989.73 | $2,870.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.84 / $2,333.50 / $3,853.54
| Professional | | $1,866.84 | $2,333.50 | $3,853.54 |