- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.10 / $6,037.30 / $6,037.30
| Professional | | $1,314.10 | $6,037.30 | $6,037.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,841.88 / $1,841.88 / $1,841.88
| Facility | | $1,841.88 | $1,841.88 | $1,841.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.34 / $1,841.88 / $1,841.88
| Professional | | $1,363.34 | $1,841.88 | $1,841.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,841.88 / $2,168.40 / $2,276.37
| Facility | | $1,841.88 | $2,168.40 | $2,276.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.52 / $1,591.68 / $2,431.10
| Professional | | $1,123.52 | $1,591.68 | $2,431.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.36 / $2,048.40 / $3,221.77
| Professional | | $1,701.36 | $2,048.40 | $3,221.77 |