- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.35 / $7,011.29 / $7,011.29
| Professional | | $1,545.35 | $7,011.29 | $7,011.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,143.69 / $2,143.69 / $2,143.69
| Facility | | $2,143.69 | $2,143.69 | $2,143.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.62 / $2,143.69 / $2,328.00
| Professional | | $1,540.62 | $2,143.69 | $2,328.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.61 / $2,495.35 / $2,598.31
| Facility | | $1,055.61 | $2,495.35 | $2,598.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.88 / $1,963.52 / $2,832.20
| Professional | | $1,308.88 | $1,963.52 | $2,832.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.07 / $2,338.76 / $3,750.88
| Professional | | $1,863.07 | $2,338.76 | $3,750.88 |