- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.38 / $8,435.67 / $8,435.67
| Professional | | $1,718.38 | $8,435.67 | $8,435.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,711.55 / $2,711.55 / $2,711.55
| Facility | | $2,711.55 | $2,711.55 | $2,711.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.16 / $2,711.55 / $2,711.55
| Professional | | $1,668.16 | $2,711.55 | $2,711.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.85 / $2,271.94 / $2,711.55
| Facility | | $1,335.85 | $2,271.94 | $2,711.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.97 / $2,337.48 / $3,514.00
| Professional | | $1,623.97 | $2,337.48 | $3,514.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.66 / $2,855.61 / $4,721.18
| Professional | | $2,080.66 | $2,855.61 | $4,721.18 |