- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.18 / $7,607.95 / $7,607.95
| Professional | | $1,690.18 | $7,607.95 | $7,607.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,325.61 / $2,325.61 / $2,325.61
| Facility | | $2,325.61 | $2,325.61 | $2,325.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,893.46 / $2,325.61 / $2,325.61
| Professional | | $1,893.46 | $2,325.61 | $2,325.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,325.61 / $3,032.25 / $3,245.99
| Facility | | $2,325.61 | $3,032.25 | $3,245.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.55 / $2,025.23 / $3,093.30
| Professional | | $1,429.55 | $2,025.23 | $3,093.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,280.19 / $2,718.71 / $4,070.00
| Professional | | $2,280.19 | $2,718.71 | $4,070.00 |