- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.11 / $7,045.21 / $7,045.21
| Professional | | $1,565.11 | $7,045.21 | $7,045.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.63 / $2,152.63 / $2,152.63
| Facility | | $2,152.63 | $2,152.63 | $2,152.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.94 / $2,152.63 / $2,152.63
| Professional | | $1,751.94 | $2,152.63 | $2,152.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.63 / $2,755.35 / $2,822.85
| Facility | | $2,152.63 | $2,755.35 | $2,822.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.09 / $1,875.82 / $2,865.10
| Professional | | $1,324.09 | $1,875.82 | $2,865.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.69 / $2,435.41 / $3,771.22
| Professional | | $2,110.69 | $2,435.41 | $3,771.22 |