- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.79 / $7,021.60 / $7,021.60
| Professional | | $1,388.79 | $7,021.60 | $7,021.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,085.32 / $2,085.32 / $2,085.32
| Facility | | $2,085.32 | $2,085.32 | $2,085.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.36 / $2,085.32 / $2,229.64
| Professional | | $1,534.36 | $2,085.32 | $2,229.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.58 / $2,501.19 / $2,557.83
| Facility | | $1,031.58 | $2,501.19 | $2,557.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.00 / $1,891.70 / $2,728.60
| Professional | | $1,261.00 | $1,891.70 | $2,728.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.48 / $2,314.21 / $3,628.76
| Professional | | $1,962.48 | $2,314.21 | $3,628.76 |