- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.10 / $6,884.75 / $6,884.75
| Professional | | $1,373.10 | $6,884.75 | $6,884.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,072.69 / $2,072.69 / $2,072.69
| Facility | | $2,072.69 | $2,072.69 | $2,072.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.31 / $2,072.69 / $2,169.69
| Professional | | $1,500.31 | $2,072.69 | $2,169.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.54 / $2,328.30 / $2,449.67
| Facility | | $1,015.54 | $2,328.30 | $2,449.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.61 / $1,894.13 / $2,732.10
| Professional | | $1,262.61 | $1,894.13 | $2,732.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.82 / $2,292.48 / $3,637.08
| Professional | | $1,826.82 | $2,292.48 | $3,637.08 |