- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,981.13 / $8,911.95 / $8,911.95
| Professional | | $1,981.13 | $8,911.95 | $8,911.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,721.02 / $2,721.02 / $2,721.02
| Facility | | $2,721.02 | $2,721.02 | $2,721.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,368.54 / $2,721.02 / $2,721.02
| Professional | | $2,368.54 | $2,721.02 | $2,721.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,721.02 / $3,267.55 / $3,294.69
| Facility | | $2,721.02 | $3,267.55 | $3,294.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.76 / $2,372.62 / $3,623.90
| Professional | | $1,674.76 | $2,372.62 | $3,623.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.77 / $3,084.01 / $4,765.60
| Professional | | $2,563.77 | $3,084.01 | $4,765.60 |