- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.58 / $7,452.27 / $7,452.27
| Professional | | $1,649.58 | $7,452.27 | $7,452.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,315.62 / $2,315.62 / $2,315.62
| Facility | | $2,315.62 | $2,315.62 | $2,315.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.40 / $2,315.62 / $2,315.62
| Professional | | $1,671.40 | $2,315.62 | $2,315.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,315.62 / $2,710.50 / $2,874.08
| Facility | | $2,315.62 | $2,710.50 | $2,874.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.17 / $1,996.35 / $3,049.20
| Professional | | $1,409.17 | $1,996.35 | $3,049.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.69 / $2,543.65 / $4,023.74
| Professional | | $2,126.69 | $2,543.65 | $4,023.74 |