- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.19 / $7,237.33 / $7,237.33
| Professional | | $1,609.19 | $7,237.33 | $7,237.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,212.57 / $2,212.57 / $2,212.57
| Facility | | $2,212.57 | $2,212.57 | $2,212.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.40 / $2,212.57 / $2,212.57
| Professional | | $1,805.40 | $2,212.57 | $2,212.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,212.57 / $2,835.30 / $2,903.18
| Facility | | $2,212.57 | $2,835.30 | $2,903.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.96 / $1,928.07 / $2,944.90
| Professional | | $1,360.96 | $1,928.07 | $2,944.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.92 / $2,502.61 / $3,873.91
| Professional | | $2,168.92 | $2,502.61 | $3,873.91 |