- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.91 / $7,673.18 / $7,673.18
| Professional | | $1,704.91 | $7,673.18 | $7,673.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,345.07 / $2,345.07 / $2,345.07
| Facility | | $2,345.07 | $2,345.07 | $2,345.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.87 / $2,345.07 / $2,345.07
| Professional | | $1,895.87 | $2,345.07 | $2,345.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,345.07 / $2,993.25 / $3,068.26
| Facility | | $2,345.07 | $2,993.25 | $3,068.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.84 / $2,042.64 / $3,119.90
| Professional | | $1,441.84 | $2,042.64 | $3,119.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.96 / $2,653.80 / $4,106.06
| Professional | | $2,299.96 | $2,653.80 | $4,106.06 |