- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.40 / $1,688.01 / $7,593.80
| Professional | | $1,461.40 | $1,688.01 | $7,593.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,321.41 / $2,321.41 / $2,321.41
| Facility | | $2,321.41 | $2,321.41 | $2,321.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.67 / $2,321.41 / $2,321.41
| Professional | | $1,876.67 | $2,321.41 | $2,321.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,321.41 / $3,036.15 / $3,214.37
| Facility | | $2,321.41 | $3,036.15 | $3,214.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.61 / $2,022.48 / $3,089.10
| Professional | | $1,427.61 | $2,022.48 | $3,089.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.04 / $2,626.20 / $4,064.43
| Professional | | $2,276.04 | $2,626.20 | $4,064.43 |