- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.86 / $7,978.06 / $7,978.06
| Professional | | $1,741.86 | $7,978.06 | $7,978.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,411.84 / $2,411.84 / $2,411.84
| Facility | | $2,411.84 | $2,411.84 | $2,411.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.00 / $2,411.84 / $2,411.84
| Professional | | $1,820.00 | $2,411.84 | $2,411.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,411.84 / $2,861.30 / $2,920.89
| Facility | | $2,411.84 | $2,861.30 | $2,920.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.16 / $2,105.42 / $3,215.80
| Professional | | $1,486.16 | $2,105.42 | $3,215.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.03 / $2,717.41 / $4,235.56
| Professional | | $2,245.03 | $2,717.41 | $4,235.56 |