- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,257.51 / $7,830.09 / $7,830.09
| Professional | | $2,257.51 | $7,830.09 | $7,830.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $2,137.15 / $2,137.15
| Facility | | $1,271.83 | $2,137.15 | $2,137.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,737.95 / $2,137.15
| Professional | | $1,271.83 | $1,737.95 | $2,137.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,134.77 / $2,035.38 / $2,137.15
| Facility | | $1,134.77 | $2,035.38 | $2,137.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,604.03 / $2,340.69
| Professional | | $1,271.83 | $1,604.03 | $2,340.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.76 / $1,015.43 / $1,564.74
| Professional | | $917.76 | $1,015.43 | $1,564.74 |