- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.22 / $6,904.67 / $6,904.67
| Professional | | $1,515.22 | $6,904.67 | $6,904.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,114.23 / $2,114.23 / $2,114.23
| Facility | | $2,114.23 | $2,114.23 | $2,114.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.88 / $2,114.23 / $2,114.23
| Professional | | $1,538.88 | $2,114.23 | $2,114.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,114.23 / $2,514.85 / $2,619.17
| Facility | | $2,114.23 | $2,514.85 | $2,619.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.65 / $1,834.12 / $2,801.40
| Professional | | $1,294.65 | $1,834.12 | $2,801.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,973.19 / $2,345.40 / $3,692.60
| Professional | | $1,973.19 | $2,345.40 | $3,692.60 |