- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.64 / $8,930.48 / $8,930.48
| Professional | | $1,800.64 | $8,930.48 | $8,930.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.31 / $2,747.31 / $2,747.31
| Facility | | $2,747.31 | $2,747.31 | $2,747.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.62 / $2,747.31 / $2,747.31
| Professional | | $1,823.62 | $2,747.31 | $2,747.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.67 / $2,856.10 / $2,994.89
| Facility | | $1,350.67 | $2,856.10 | $2,994.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.20 / $2,490.56 / $3,592.40
| Professional | | $1,660.20 | $2,490.56 | $3,592.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.96 / $2,861.72 / $4,782.25
| Professional | | $2,318.96 | $2,861.72 | $4,782.25 |