- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.73 / $11,179.20 / $11,179.20
| Professional | | $1,526.73 | $11,179.20 | $11,179.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $3,187.71 / $3,187.71
| Facility | | $1,815.81 | $3,187.71 | $3,187.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.81 / $2,592.26 / $3,187.71
| Professional | | $1,815.81 | $2,592.26 | $3,187.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.13 / $3,035.91 / $3,187.71
| Facility | | $1,620.13 | $3,035.91 | $3,187.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,815.81 / $2,392.52 / $3,190.02
| Professional | | $1,815.81 | $2,392.52 | $3,190.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.30 / $1,449.74 / $2,218.50
| Professional | | $1,310.30 | $1,449.74 | $2,218.50 |