- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.85 / $6,964.73 / $6,964.73
| Professional | | $1,523.85 | $6,964.73 | $6,964.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,096.89 / $2,096.89 / $2,096.89
| Facility | | $2,096.89 | $2,096.89 | $2,096.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.89 / $2,096.89 / $2,110.73
| Professional | | $2,096.89 | $2,096.89 | $2,110.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,096.89 / $2,096.89 / $2,096.89
| Facility | | $2,096.89 | $2,096.89 | $2,096.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.58 / $1,945.08 / $2,805.60
| Professional | | $1,296.58 | $1,945.08 | $2,805.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.96 / $2,443.41 / $3,688.89
| Professional | | $2,065.96 | $2,443.41 | $3,688.89 |