- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.69 / $7,429.11 / $7,429.11
| Professional | | $1,650.69 | $7,429.11 | $7,429.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,270.40 / $2,270.40 / $2,270.40
| Facility | | $2,270.40 | $2,270.40 | $2,270.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.74 / $2,270.40 / $2,270.40
| Professional | | $1,968.74 | $2,270.40 | $2,270.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,270.40 / $2,722.28 / $2,726.10
| Facility | | $2,270.40 | $2,722.28 | $2,726.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.23 / $1,978.02 / $3,021.20
| Professional | | $1,396.23 | $1,978.02 | $3,021.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.94 / $2,567.98 / $3,972.88
| Professional | | $2,138.94 | $2,567.98 | $3,972.88 |