- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.00 / $7,832.74 / $7,832.74
| Professional | | $1,598.00 | $7,832.74 | $7,832.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.01 / $2,507.01 / $2,507.01
| Facility | | $2,507.01 | $2,507.01 | $2,507.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.17 / $2,507.01 / $2,708.63
| Professional | | $1,611.17 | $2,507.01 | $2,708.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,234.31 / $2,663.70 / $2,855.74
| Facility | | $1,234.31 | $2,663.70 | $2,855.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.57 / $2,258.59 / $3,257.80
| Professional | | $1,505.57 | $2,258.59 | $3,257.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,347.81 / $2,709.01 / $4,372.47
| Professional | | $2,347.81 | $2,709.01 | $4,372.47 |