- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.14 / $1,445.28 / $7,772.29
| Professional | | $1,360.14 | $1,445.28 | $7,772.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,370.83 / $2,370.83 / $2,370.83
| Facility | | $2,370.83 | $2,370.83 | $2,370.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.00 / $2,370.83 / $2,370.83
| Professional | | $1,714.00 | $2,370.83 | $2,370.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,370.83 / $2,776.80 / $2,895.59
| Facility | | $2,370.83 | $2,776.80 | $2,895.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.34 / $2,050.42 / $3,131.80
| Professional | | $1,447.34 | $2,050.42 | $3,131.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.71 / $2,641.19 / $4,147.68
| Professional | | $2,178.71 | $2,641.19 | $4,147.68 |