- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.24 / $7,052.83 / $7,052.83
| Professional | | $1,593.24 | $7,052.83 | $7,052.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,265.15 / $2,265.15 / $2,265.15
| Facility | | $2,265.15 | $2,265.15 | $2,265.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.95 / $2,265.15 / $2,352.44
| Professional | | $1,620.95 | $2,265.15 | $2,352.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.84 / $2,654.60 / $2,664.09
| Facility | | $1,115.84 | $2,654.60 | $2,664.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.23 / $2,061.55 / $2,973.60
| Professional | | $1,374.23 | $2,061.55 | $2,973.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,082.60 / $2,403.00 / $3,975.64
| Professional | | $2,082.60 | $2,403.00 | $3,975.64 |