- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.41 / $2,161.48 / $8,335.37
| Professional | | $1,700.41 | $2,161.48 | $8,335.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,683.68 / $2,683.68 / $2,683.68
| Facility | | $2,683.68 | $2,683.68 | $2,683.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.89 / $2,509.58 / $2,683.68
| Professional | | $1,395.89 | $2,509.58 | $2,683.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,322.24 / $1,722.29 / $2,683.68
| Facility | | $1,322.24 | $1,722.29 | $2,683.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.80 / $2,509.58 / $3,479.00
| Professional | | $1,607.80 | $2,509.58 | $3,479.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.17 / $2,676.31 / $3,057.27
| Professional | | $2,245.17 | $2,676.31 | $3,057.27 |