- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.85 / $7,653.96 / $7,653.96
| Professional | | $1,558.85 | $7,653.96 | $7,653.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,451.28 / $2,451.28 / $2,451.28
| Facility | | $2,451.28 | $2,451.28 | $2,451.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.78 / $2,451.28 / $2,628.31
| Professional | | $1,570.78 | $2,451.28 | $2,628.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.32 / $2,583.10 / $2,773.51
| Facility | | $1,207.32 | $2,583.10 | $2,773.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.98 / $2,205.19 / $3,180.80
| Professional | | $1,469.98 | $2,205.19 | $3,180.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,070.82 / $2,583.10 / $4,272.57
| Professional | | $2,070.82 | $2,583.10 | $4,272.57 |