- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.15 / $7,239.33 / $7,239.33
| Professional | | $1,422.15 | $7,239.33 | $7,239.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,278.82 / $2,278.82 / $2,278.82
| Facility | | $2,278.82 | $2,278.82 | $2,278.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.66 / $2,278.82 / $2,452.55
| Professional | | $1,578.66 | $2,278.82 | $2,452.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.84 / $2,549.30 / $2,733.67
| Facility | | $1,116.84 | $2,549.30 | $2,733.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.91 / $2,044.57 / $2,949.10
| Professional | | $1,362.91 | $2,044.57 | $2,949.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.23 / $2,437.80 / $3,978.42
| Professional | | $2,000.23 | $2,437.80 | $3,978.42 |