- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.48 / $7,897.68 / $7,897.68
| Professional | | $1,723.48 | $7,897.68 | $7,897.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.06 / $2,406.06 / $2,406.06
| Facility | | $2,406.06 | $2,406.06 | $2,406.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.16 / $2,406.06 / $2,406.06
| Professional | | $1,794.16 | $2,406.06 | $2,406.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.06 / $2,845.05 / $2,949.35
| Facility | | $2,406.06 | $2,845.05 | $2,949.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.28 / $2,084.35 / $3,183.60
| Professional | | $1,471.28 | $2,084.35 | $3,183.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.28 / $2,641.43 / $4,211.51
| Professional | | $2,232.28 | $2,641.43 | $4,211.51 |