- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.52 / $9,332.37 / $9,332.37
| Professional | | $1,725.52 | $9,332.37 | $9,332.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,786.21 / $2,786.21 / $2,786.21
| Facility | | $2,786.21 | $2,786.21 | $2,786.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.63 / $2,786.21 / $2,991.48
| Professional | | $1,972.63 | $2,786.21 | $2,991.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.12 / $3,095.95 / $3,344.03
| Facility | | $1,381.12 | $3,095.95 | $3,344.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.20 / $2,540.06 / $3,663.80
| Professional | | $1,693.20 | $2,540.06 | $3,663.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.14 / $3,038.49 / $4,889.55
| Professional | | $2,429.14 | $3,038.49 | $4,889.55 |