- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.89 / $8,008.29 / $8,008.29
| Professional | | $1,710.89 | $8,008.29 | $8,008.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,440.76 / $2,440.76 / $2,440.76
| Facility | | $2,440.76 | $2,440.76 | $2,440.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.86 / $2,440.76 / $2,440.76
| Professional | | $1,818.86 | $2,440.76 | $2,440.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.30 / $1,502.87 / $2,440.76
| Facility | | $1,202.30 | $1,502.87 | $2,440.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.19 / $2,228.01 / $3,213.70
| Professional | | $1,485.19 | $2,228.01 | $3,213.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,077.73 / $2,607.35 / $4,291.08
| Professional | | $2,077.73 | $2,607.35 | $4,291.08 |