- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.90 / $9,175.45 / $9,175.45
| Professional | | $1,921.90 | $9,175.45 | $9,175.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,735.74 / $2,735.74 / $2,735.74
| Facility | | $2,735.74 | $2,735.74 | $2,735.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.80 / $2,735.74 / $2,869.26
| Professional | | $1,817.80 | $2,735.74 | $2,869.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,340.30 / $2,898.35 / $3,200.45
| Facility | | $1,340.30 | $2,898.35 | $3,200.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.94 / $2,520.16 / $3,635.10
| Professional | | $1,679.94 | $2,520.16 | $3,635.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,557.89 / $2,904.73 / $4,830.34
| Professional | | $2,557.89 | $2,904.73 | $4,830.34 |