- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.21 / $7,404.66 / $7,404.66
| Professional | | $1,615.21 | $7,404.66 | $7,404.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,241.48 / $2,241.48 / $2,241.48
| Facility | | $2,241.48 | $2,241.48 | $2,241.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.57 / $2,241.48 / $2,241.48
| Professional | | $1,559.57 | $2,241.48 | $2,241.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,241.48 / $2,506.40 / $2,692.55
| Facility | | $2,241.48 | $2,506.40 | $2,692.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.08 / $1,953.73 / $2,984.10
| Professional | | $1,379.08 | $1,953.73 | $2,984.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.58 / $2,476.23 / $3,934.01
| Professional | | $1,972.58 | $2,476.23 | $3,934.01 |