- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.73 / $8,183.93 / $8,183.93
| Professional | | $1,819.73 | $8,183.93 | $8,183.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,499.65 / $2,499.65 / $2,499.65
| Facility | | $2,499.65 | $2,499.65 | $2,499.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.24 / $2,499.65 / $2,499.65
| Professional | | $2,029.24 | $2,499.65 | $2,499.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,499.65 / $3,269.50 / $3,392.10
| Facility | | $2,499.65 | $3,269.50 | $3,392.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.57 / $2,179.67 / $3,329.20
| Professional | | $1,538.57 | $2,179.67 | $3,329.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.89 / $2,925.79 / $4,377.09
| Professional | | $2,453.89 | $2,925.79 | $4,377.09 |