- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.32 / $8,495.53 / $8,495.53
| Professional | | $1,854.32 | $8,495.53 | $8,495.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.58 / $2,569.58 / $2,569.58
| Facility | | $2,569.58 | $2,569.58 | $2,569.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.50 / $2,569.58 / $2,569.58
| Professional | | $1,931.50 | $2,569.58 | $2,569.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.58 / $3,093.35 / $3,203.61
| Facility | | $2,569.58 | $3,093.35 | $3,203.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.56 / $2,242.00 / $3,424.40
| Professional | | $1,582.56 | $2,242.00 | $3,424.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.09 / $2,891.41 / $4,512.14
| Professional | | $2,427.09 | $2,891.41 | $4,512.14 |