- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.19 / $8,056.74 / $8,056.74
| Professional | | $1,766.19 | $8,056.74 | $8,056.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,422.36 / $2,422.36 / $2,422.36
| Facility | | $2,422.36 | $2,422.36 | $2,422.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.69 / $2,422.36 / $2,422.36
| Professional | | $1,409.69 | $2,422.36 | $2,422.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.15 / $2,341.52 / $2,422.36
| Facility | | $2,282.15 | $2,341.52 | $2,422.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.69 / $2,126.51 / $3,248.00
| Professional | | $1,409.69 | $2,126.51 | $3,248.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,164.82 / $2,717.54 / $4,265.17
| Professional | | $2,164.82 | $2,717.54 | $4,265.17 |