- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.98 / $8,692.44 / $8,692.44
| Professional | | $2,070.98 | $8,692.44 | $8,692.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,568.53 / $2,568.53 / $2,568.53
| Facility | | $2,568.53 | $2,568.53 | $2,568.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.65 / $2,568.53 / $2,765.66
| Professional | | $1,891.65 | $2,568.53 | $2,765.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.01 / $3,084.90 / $3,162.50
| Facility | | $1,270.01 | $3,084.90 | $3,162.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.45 / $2,330.41 / $3,361.40
| Professional | | $1,553.45 | $2,330.41 | $3,361.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.73 / $2,871.60 / $4,471.45
| Professional | | $2,488.73 | $2,871.60 | $4,471.45 |