- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.88 / $8,295.83 / $8,295.83
| Professional | | $1,810.88 | $8,295.83 | $8,295.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.52 / $2,527.52 / $2,527.52
| Facility | | $2,527.52 | $2,527.52 | $2,527.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.53 / $2,527.52 / $2,527.52
| Professional | | $1,837.53 | $2,527.52 | $2,527.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,527.52 / $3,007.55 / $3,125.18
| Facility | | $2,527.52 | $3,007.55 | $3,125.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.36 / $2,189.30 / $3,343.90
| Professional | | $1,545.36 | $2,189.30 | $3,343.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,359.77 / $2,824.21 / $4,424.26
| Professional | | $2,359.77 | $2,824.21 | $4,424.26 |