- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.86 / $7,512.38 / $7,512.38
| Professional | | $1,653.86 | $7,512.38 | $7,512.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,294.07 / $2,294.07 / $2,294.07
| Facility | | $2,294.07 | $2,294.07 | $2,294.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,688.22 / $2,294.07 / $2,500.27
| Professional | | $1,688.22 | $2,294.07 | $2,500.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,130.17 / $2,698.15 / $2,811.46
| Facility | | $1,130.17 | $2,698.15 | $2,811.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.43 / $2,100.86 / $3,030.30
| Professional | | $1,400.43 | $2,100.86 | $3,030.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.00 / $2,548.81 / $4,011.72
| Professional | | $2,117.00 | $2,548.81 | $4,011.72 |