- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.88 / $1,750.44 / $8,029.55
| Professional | | $1,416.88 | $1,750.44 | $8,029.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,447.60 / $2,447.60 / $2,447.60
| Facility | | $2,447.60 | $2,447.60 | $2,447.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.13 / $2,447.60 / $2,447.60
| Professional | | $1,830.13 | $2,447.60 | $2,447.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,447.60 / $2,905.50 / $3,015.13
| Facility | | $2,447.60 | $2,905.50 | $3,015.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.89 / $2,117.80 / $3,234.70
| Professional | | $1,494.89 | $2,117.80 | $3,234.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.69 / $2,729.41 / $4,284.60
| Professional | | $2,279.69 | $2,729.41 | $4,284.60 |