- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.66 / $7,323.64 / $7,323.64
| Professional | | $1,599.66 | $7,323.64 | $7,323.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.35 / $2,218.35 / $2,218.35
| Facility | | $2,218.35 | $2,218.35 | $2,218.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.17 / $2,218.35 / $2,218.35
| Professional | | $1,664.17 | $2,218.35 | $2,218.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.35 / $2,674.75 / $2,801.98
| Facility | | $2,218.35 | $2,674.75 | $2,801.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.82 / $1,934.94 / $2,955.40
| Professional | | $1,365.82 | $1,934.94 | $2,955.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.65 / $2,491.19 / $3,895.17
| Professional | | $2,098.65 | $2,491.19 | $3,895.17 |