- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.59 / $8,244.19 / $8,244.19
| Professional | | $1,652.59 | $8,244.19 | $8,244.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.54 / $2,507.54 / $2,507.54
| Facility | | $2,507.54 | $2,507.54 | $2,507.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.41 / $2,507.54 / $2,630.64
| Professional | | $1,746.41 | $2,507.54 | $2,630.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.90 / $2,700.75 / $2,941.76
| Facility | | $1,230.90 | $2,700.75 | $2,941.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.15 / $2,311.96 / $3,334.80
| Professional | | $1,541.15 | $2,311.96 | $3,334.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.05 / $2,659.20 / $4,431.68
| Professional | | $2,119.05 | $2,659.20 | $4,431.68 |