- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.13 / $8,036.52 / $8,036.52
| Professional | | $1,787.13 | $8,036.52 | $8,036.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,455.48 / $2,455.48 / $2,455.48
| Facility | | $2,455.48 | $2,455.48 | $2,455.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.20 / $2,455.48 / $2,455.48
| Professional | | $1,980.20 | $2,455.48 | $2,455.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,455.48 / $3,136.90 / $3,394.00
| Facility | | $2,455.48 | $3,136.90 | $3,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.07 / $2,140.71 / $3,269.70
| Professional | | $1,511.07 | $2,140.71 | $3,269.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,409.16 / $2,779.80 / $4,302.16
| Professional | | $2,409.16 | $2,779.80 | $4,302.16 |