- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.89 / $7,780.00 / $7,780.00
| Professional | | $1,695.89 | $7,780.00 | $7,780.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,372.41 / $2,372.41 / $2,372.41
| Facility | | $2,372.41 | $2,372.41 | $2,372.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.04 / $2,372.41 / $2,372.41
| Professional | | $1,768.04 | $2,372.41 | $2,372.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,372.41 / $2,814.50 / $2,920.89
| Facility | | $2,372.41 | $2,814.50 | $2,920.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.63 / $2,052.27 / $3,134.60
| Professional | | $1,448.63 | $2,052.27 | $3,134.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.31 / $2,643.61 / $4,150.47
| Professional | | $2,208.31 | $2,643.61 | $4,150.47 |