- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.35 / $7,660.09 / $7,660.09
| Professional | | $1,832.35 | $7,660.09 | $7,660.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,274.09 / $2,274.09 / $2,274.09
| Facility | | $2,274.09 | $2,274.09 | $2,274.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,676.93 / $2,274.09 / $2,435.09
| Professional | | $1,676.93 | $2,274.09 | $2,435.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,123.80 / $2,731.95 / $2,791.86
| Facility | | $1,123.80 | $2,731.95 | $2,791.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.55 / $2,062.04 / $2,974.30
| Professional | | $1,374.55 | $2,062.04 | $2,974.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,143.53 / $2,483.90 / $3,957.13
| Professional | | $2,143.53 | $2,483.90 | $3,957.13 |