- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.71 / $1,510.00 / $1,510.00
| Professional | | $1,408.71 | $1,510.00 | $1,510.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,185.21 / $2,185.21 / $2,185.21
| Facility | | $2,185.21 | $2,185.21 | $2,185.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.44 / $1,966.70 / $2,185.21
| Professional | | $1,857.44 | $1,966.70 | $2,185.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.07 / $833.07 / $2,185.21
| Facility | | $833.07 | $833.07 | $2,185.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.44 / $2,185.21 / $2,904.45
| Professional | | $1,857.44 | $2,185.21 | $2,904.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.26 / $2,277.08 / $2,591.16
| Professional | | $2,002.26 | $2,277.08 | $2,591.16 |