- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.26 / $6,762.74 / $6,762.74
| Professional | | $1,484.26 | $6,762.74 | $6,762.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,067.44 / $2,067.44 / $2,067.44
| Facility | | $2,067.44 | $2,067.44 | $2,067.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.25 / $2,067.44 / $2,067.44
| Professional | | $1,404.25 | $2,067.44 | $2,067.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,067.44 / $2,249.65 / $2,377.57
| Facility | | $2,067.44 | $2,249.65 | $2,377.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.83 / $1,794.70 / $2,741.20
| Professional | | $1,266.83 | $1,794.70 | $2,741.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.50 / $2,249.65 / $3,621.36
| Professional | | $1,801.50 | $2,249.65 | $3,621.36 |