- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.12 / $6,807.46 / $6,807.46
| Professional | | $1,484.12 | $6,807.46 | $6,807.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,069.02 / $2,069.02 / $2,069.02
| Facility | | $2,069.02 | $2,069.02 | $2,069.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.24 / $2,069.02 / $2,069.02
| Professional | | $1,583.24 | $2,069.02 | $2,069.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,069.02 / $2,496.00 / $2,572.38
| Facility | | $2,069.02 | $2,496.00 | $2,572.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.83 / $1,794.70 / $2,741.20
| Professional | | $1,266.83 | $1,794.70 | $2,741.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,958.40 / $2,316.60 / $3,626.93
| Professional | | $1,958.40 | $2,316.60 | $3,626.93 |