- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.46 / $7,359.69 / $7,359.69
| Professional | | $1,634.46 | $7,359.69 | $7,359.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,246.21 / $2,246.21 / $2,246.21
| Facility | | $2,246.21 | $2,246.21 | $2,246.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.05 / $2,246.21 / $2,246.21
| Professional | | $1,760.05 | $2,246.21 | $2,246.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,246.21 / $2,963.35 / $3,094.19
| Facility | | $2,246.21 | $2,963.35 | $3,094.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.99 / $1,957.86 / $2,990.40
| Professional | | $1,381.99 | $1,957.86 | $2,990.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.36 / $2,545.80 / $6,259.43
| Professional | | $2,206.36 | $2,545.80 | $6,259.43 |