- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,942.88 / $8,844.48 / $8,844.48
| Professional | | $1,942.88 | $8,844.48 | $8,844.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,685.79 / $2,685.79 / $2,685.79
| Facility | | $2,685.79 | $2,685.79 | $2,685.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.21 / $2,685.79 / $2,930.37
| Professional | | $1,798.21 | $2,685.79 | $2,930.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.96 / $3,116.75 / $3,245.36
| Facility | | $1,320.96 | $3,116.75 | $3,245.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.06 / $2,464.84 / $3,555.30
| Professional | | $1,643.06 | $2,464.84 | $3,555.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,445.46 / $3,006.00 / $4,697.14
| Professional | | $2,445.46 | $3,006.00 | $4,697.14 |