- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.62 / $7,125.14 / $7,125.14
| Professional | | $1,572.62 | $7,125.14 | $7,125.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,174.17 / $2,174.17 / $2,174.17
| Facility | | $2,174.17 | $2,174.17 | $2,174.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.71 / $2,174.17 / $2,174.17
| Professional | | $1,617.71 | $2,174.17 | $2,174.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,069.70 / $2,514.19 / $2,578.07
| Facility | | $1,069.70 | $2,514.19 | $2,578.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.91 / $1,995.07 / $2,877.70
| Professional | | $1,329.91 | $1,995.07 | $2,877.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.68 / $2,422.80 / $3,807.30
| Professional | | $1,972.68 | $2,422.80 | $3,807.30 |