- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.26 / $1,967.62 / $7,708.49
| Professional | | $1,346.26 | $1,967.62 | $7,708.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,308.79 / $2,308.79 / $2,308.79
| Facility | | $2,308.79 | $2,308.79 | $2,308.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.92 / $2,308.79 / $2,556.73
| Professional | | $1,265.92 | $2,308.79 | $2,556.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.41 / $1,570.81 / $2,308.79
| Facility | | $1,142.41 | $1,570.81 | $2,308.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.16 / $2,308.79 / $3,155.63
| Professional | | $1,442.16 | $2,308.79 | $3,155.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.25 / $1,819.25 / $1,819.25
| Facility | | $1,819.25 | $1,819.25 | $1,819.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,050.14 / $2,491.48 / $2,884.86
| Professional | | $2,050.14 | $2,491.48 | $2,884.86 |