- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,485.76 / $7,198.09 / $7,198.09
| Professional | | $1,485.76 | $7,198.09 | $7,198.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,213.62 / $2,213.62 / $2,213.62
| Facility | | $2,213.62 | $2,213.62 | $2,213.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.03 / $2,213.62 / $2,333.82
| Professional | | $1,514.03 | $2,213.62 | $2,333.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.73 / $2,414.10 / $2,559.10
| Facility | | $1,085.73 | $2,414.10 | $2,559.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.73 / $2,020.30 / $2,914.10
| Professional | | $1,346.73 | $2,020.30 | $2,914.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.14 / $2,376.96 / $3,865.58
| Professional | | $1,894.14 | $2,376.96 | $3,865.58 |