- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.70 / $2,061.67 / $7,986.48
| Professional | | $1,401.70 | $2,061.67 | $7,986.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,562.21 / $2,562.21 / $2,562.21
| Facility | | $2,562.21 | $2,562.21 | $2,562.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.61 / $2,562.21 / $2,747.04
| Professional | | $1,353.61 | $2,562.21 | $2,747.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.28 / $1,665.33 / $2,562.21
| Facility | | $1,262.28 | $1,665.33 | $2,562.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.63 / $2,561.19 / $3,325.00
| Professional | | $1,536.63 | $2,561.19 | $3,325.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.76 / $2,625.28 / $2,938.23
| Professional | | $2,157.76 | $2,625.28 | $2,938.23 |