- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.03 / $7,354.86 / $7,354.86
| Professional | | $1,607.03 | $7,354.86 | $7,354.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,227.81 / $2,227.81 / $2,227.81
| Facility | | $2,227.81 | $2,227.81 | $2,227.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.90 / $2,227.81 / $2,227.81
| Professional | | $1,611.90 | $2,227.81 | $2,227.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,227.81 / $2,611.69 / $2,721.65
| Facility | | $2,227.81 | $2,611.69 | $2,721.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.96 / $1,943.65 / $2,968.70
| Professional | | $1,371.96 | $1,943.65 | $2,968.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.17 / $2,502.01 / $3,909.96
| Professional | | $2,049.17 | $2,502.01 | $3,909.96 |