- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.85 / $6,637.10 / $6,637.10
| Professional | | $1,465.85 | $6,637.10 | $6,637.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,020.12 / $2,020.12 / $2,020.12
| Facility | | $2,020.12 | $2,020.12 | $2,020.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,587.51 / $2,020.12 / $2,020.12
| Professional | | $1,587.51 | $2,020.12 | $2,020.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,020.12 / $2,518.10 / $2,610.96
| Facility | | $2,020.12 | $2,518.10 | $2,610.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.89 / $1,760.79 / $2,689.40
| Professional | | $1,242.89 | $1,760.79 | $2,689.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.75 / $2,283.00 / $3,534.42
| Professional | | $1,975.75 | $2,283.00 | $3,534.42 |