- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.30 / $7,936.88 / $7,936.88
| Professional | | $1,734.30 | $7,936.88 | $7,936.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,394.48 / $2,394.48 / $2,394.48
| Facility | | $2,394.48 | $2,394.48 | $2,394.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.21 / $2,394.48 / $2,394.48
| Professional | | $1,807.21 | $2,394.48 | $2,394.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,394.48 / $2,867.15 / $2,972.12
| Facility | | $2,394.48 | $2,867.15 | $2,972.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.40 / $2,094.42 / $3,199.00
| Professional | | $1,478.40 | $2,094.42 | $3,199.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,249.61 / $2,707.80 / $6,263.38
| Professional | | $2,249.61 | $2,707.80 | $6,263.38 |