- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.73 / $6,785.05 / $6,785.05
| Professional | | $1,475.73 | $6,785.05 | $6,785.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.65 / $2,071.65 / $2,071.65
| Facility | | $2,071.65 | $2,071.65 | $2,071.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.95 / $2,071.65 / $2,071.65
| Professional | | $1,437.95 | $2,071.65 | $2,071.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,071.65 / $2,486.25 / $2,553.40
| Facility | | $2,071.65 | $2,486.25 | $2,553.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.30 / $1,788.29 / $2,731.40
| Professional | | $1,262.30 | $1,788.29 | $2,731.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.75 / $2,299.79 / $3,621.36
| Professional | | $1,950.75 | $2,299.79 | $3,621.36 |