- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.08 / $7,698.63 / $7,698.63
| Professional | | $1,571.08 | $7,698.63 | $7,698.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,469.67 / $2,469.67 / $2,469.67
| Facility | | $2,469.67 | $2,469.67 | $2,469.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.43 / $2,469.67 / $2,648.68
| Professional | | $1,576.43 | $2,469.67 | $2,648.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,215.86 / $2,575.94 / $2,776.68
| Facility | | $1,215.86 | $2,575.94 | $2,776.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.28 / $2,223.64 / $3,207.40
| Professional | | $1,482.28 | $2,223.64 | $3,207.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.16 / $2,575.94 / $4,304.01
| Professional | | $2,081.16 | $2,575.94 | $4,304.01 |