- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.07 / $7,486.78 / $7,486.78
| Professional | | $1,632.07 | $7,486.78 | $7,486.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.02 / $2,283.02 / $2,283.02
| Facility | | $2,283.02 | $2,283.02 | $2,283.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.47 / $2,283.02 / $2,283.02
| Professional | | $1,675.47 | $2,283.02 | $2,283.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.02 / $2,687.10 / $2,795.02
| Facility | | $2,283.02 | $2,687.10 | $2,795.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.29 / $1,975.27 / $3,017.00
| Professional | | $1,394.29 | $1,975.27 | $3,017.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.35 / $2,542.81 / $3,993.22
| Professional | | $2,108.35 | $2,542.81 | $3,993.22 |