- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.16 / $9,051.53 / $9,051.53
| Professional | | $1,236.16 | $9,051.53 | $9,051.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,549.06 / $2,823.20 / $2,823.20
| Facility | | $1,549.06 | $2,823.20 | $2,823.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.06 / $2,295.84 / $2,823.20
| Professional | | $1,549.06 | $2,295.84 | $2,823.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,311.79 / $2,688.76 / $2,823.20
| Facility | | $1,311.79 | $2,688.76 | $2,823.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.06 / $2,118.92 / $2,825.24
| Professional | | $1,549.06 | $2,118.92 | $2,825.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.93 / $1,173.83 / $1,343.71
| Professional | | $1,060.93 | $1,173.83 | $1,343.71 |