- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.25 / $8,113.96 / $8,113.96
| Professional | | $2,073.25 | $8,113.96 | $8,113.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,485.46 / $2,485.46 / $2,485.46
| Facility | | $2,485.46 | $2,485.46 | $2,485.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.91 / $2,485.46 / $2,485.46
| Professional | | $1,583.91 | $2,485.46 | $2,485.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.64 / $2,529.80 / $2,635.63
| Facility | | $1,226.64 | $2,529.80 | $2,635.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.07 / $2,283.34 / $3,293.50
| Professional | | $1,522.07 | $2,283.34 | $3,293.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,158.71 / $2,663.95 / $4,352.10
| Professional | | $2,158.71 | $2,663.95 | $4,352.10 |