- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.05 / $6,732.16 / $6,732.16
| Professional | | $1,466.05 | $6,732.16 | $6,732.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,054.30 / $2,054.30 / $2,054.30
| Facility | | $2,054.30 | $2,054.30 | $2,054.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.69 / $2,054.30 / $2,054.30
| Professional | | $1,426.69 | $2,054.30 | $2,054.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,054.30 / $2,346.50 / $2,462.96
| Facility | | $2,054.30 | $2,346.50 | $2,462.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.24 / $1,775.45 / $2,711.80
| Professional | | $1,253.24 | $1,775.45 | $2,711.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.10 / $2,284.19 / $3,591.77
| Professional | | $1,841.10 | $2,284.19 | $3,591.77 |