- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.31 / $7,025.34 / $7,025.34
| Professional | | $1,534.31 | $7,025.34 | $7,025.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,121.08 / $2,121.08 / $2,121.08
| Facility | | $2,121.08 | $2,121.08 | $2,121.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.21 / $2,121.08 / $2,121.08
| Professional | | $1,519.21 | $2,121.08 | $2,121.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,121.08 / $2,511.60 / $2,604.64
| Facility | | $2,121.08 | $2,511.60 | $2,604.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.88 / $1,854.28 / $2,832.20
| Professional | | $1,308.88 | $1,854.28 | $2,832.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.89 / $2,392.80 / $3,728.66
| Professional | | $1,967.89 | $2,392.80 | $3,728.66 |