- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,526.06 / $8,761.51 / $8,761.51
| Professional | | $2,526.06 | $8,761.51 | $8,761.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $2,391.38 / $2,391.38
| Facility | | $1,654.54 | $2,391.38 | $2,391.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,944.69 / $2,391.38
| Professional | | $1,654.54 | $1,944.69 | $2,391.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,269.76 / $2,277.50 / $2,391.38
| Facility | | $1,269.76 | $2,277.50 | $2,391.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,794.83 / $2,619.13
| Professional | | $1,654.54 | $1,794.83 | $2,619.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.93 / $1,136.22 / $1,750.88
| Professional | | $1,026.93 | $1,136.22 | $1,750.88 |