- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.89 / $1,543.90 / $3,083.19
| Professional | | $1,179.89 | $1,543.90 | $3,083.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.37 / $2,387.48 / $3,993.75
| Professional | | $2,029.37 | $2,387.48 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.62 / $2,285.44 / $2,285.44
| Professional | | $2,098.62 | $2,285.44 | $2,285.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.45 / $1,399.08 / $2,484.11
| Professional | | $1,028.45 | $1,399.08 | $2,484.11 |