- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.08 / $7,747.64 / $7,747.64
| Professional | | $1,058.08 | $7,747.64 | $7,747.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $2,114.65 / $2,114.65
| Facility | | $1,544.16 | $2,114.65 | $2,114.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,719.65 / $2,114.65
| Professional | | $1,544.16 | $1,719.65 | $2,114.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.82 / $2,013.95 / $2,114.65
| Facility | | $1,122.82 | $2,013.95 | $2,114.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,587.13 / $2,180.36
| Professional | | $1,544.16 | $1,587.13 | $2,180.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.10 / $1,004.74 / $1,537.52
| Professional | | $908.10 | $1,004.74 | $1,537.52 |