- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.05 / $7,700.08 / $7,700.08
| Professional | | $1,845.05 | $7,700.08 | $7,700.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,285.65 / $2,285.65 / $2,285.65
| Facility | | $2,285.65 | $2,285.65 | $2,285.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.48 / $2,285.65 / $2,450.80
| Professional | | $1,683.48 | $2,285.65 | $2,450.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,129.25 / $2,742.35 / $2,805.77
| Facility | | $1,129.25 | $2,742.35 | $2,805.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.93 / $2,076.11 / $2,994.60
| Professional | | $1,383.93 | $2,076.11 | $2,994.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,151.69 / $2,538.00 / $3,981.21
| Professional | | $2,151.69 | $2,538.00 | $3,981.21 |