- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.36 / $8,072.83 / $8,072.83
| Professional | | $1,625.36 | $8,072.83 | $8,072.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,467.58 / $2,467.58 / $2,467.58
| Facility | | $2,467.58 | $2,467.58 | $2,467.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.09 / $2,467.58 / $2,559.05
| Professional | | $1,682.09 | $2,467.58 | $2,559.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.39 / $2,617.55 / $2,867.12
| Facility | | $1,209.39 | $2,617.55 | $2,867.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.80 / $2,279.94 / $3,288.60
| Professional | | $1,519.80 | $2,279.94 | $3,288.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.77 / $2,577.27 / $4,364.14
| Professional | | $2,053.77 | $2,577.27 | $4,364.14 |