- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.95 / $7,902.61 / $7,902.61
| Professional | | $1,712.95 | $7,902.61 | $7,902.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,396.60 / $2,396.60 / $2,396.60
| Facility | | $2,396.60 | $2,396.60 | $2,396.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.67 / $2,396.60 / $2,396.60
| Professional | | $1,815.67 | $2,396.60 | $2,396.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,396.60 / $2,853.50 / $2,956.31
| Facility | | $2,396.60 | $2,853.50 | $2,956.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.84 / $2,073.81 / $3,167.50
| Professional | | $1,463.84 | $2,073.81 | $3,167.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.90 / $2,685.60 / $4,164.34
| Professional | | $2,238.90 | $2,685.60 | $4,164.34 |