- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.01 / $1,400.01 / $7,853.26
| Professional | | $1,400.01 | $1,400.01 | $7,853.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,424.46 / $2,424.46 / $2,424.46
| Facility | | $2,424.46 | $2,424.46 | $2,424.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.30 / $2,424.46 / $2,560.21
| Professional | | $1,583.30 | $2,424.46 | $2,560.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.34 / $2,483.00 / $2,607.80
| Facility | | $1,191.34 | $2,483.00 | $2,607.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.78 / $2,198.89 / $3,171.70
| Professional | | $1,465.78 | $2,198.89 | $3,171.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,038.39 / $2,490.33 / $4,219.83
| Professional | | $2,038.39 | $2,490.33 | $4,219.83 |