- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.32 / $7,367.81 / $7,367.81
| Professional | | $1,622.32 | $7,367.81 | $7,367.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,239.91 / $2,239.91 / $2,239.91
| Facility | | $2,239.91 | $2,239.91 | $2,239.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.58 / $2,239.91 / $2,239.91
| Professional | | $1,756.58 | $2,239.91 | $2,239.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,239.91 / $2,788.50 / $2,890.53
| Facility | | $2,239.91 | $2,788.50 | $2,890.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.85 / $1,949.15 / $2,977.10
| Professional | | $1,375.85 | $1,949.15 | $2,977.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.90 / $2,533.80 / $3,946.05
| Professional | | $2,187.90 | $2,533.80 | $3,946.05 |