- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.64 / $6,623.10 / $6,623.10
| Professional | | $1,472.64 | $6,623.10 | $6,623.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,024.86 / $2,024.86 / $2,024.86
| Facility | | $2,024.86 | $2,024.86 | $2,024.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.93 / $2,024.86 / $2,024.86
| Professional | | $1,639.93 | $2,024.86 | $2,024.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,024.86 / $2,577.90 / $2,798.81
| Facility | | $2,024.86 | $2,577.90 | $2,798.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.80 / $1,764.91 / $2,695.70
| Professional | | $1,245.80 | $1,764.91 | $2,695.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.29 / $2,417.31 / $3,547.36
| Professional | | $1,983.29 | $2,417.31 | $3,547.36 |