- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,274.98 / $7,890.68 / $7,890.68
| Professional | | $2,274.98 | $7,890.68 | $7,890.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.27 / $2,296.04 / $2,296.04
| Facility | | $1,637.27 | $2,296.04 | $2,296.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.27 / $1,867.17 / $2,296.04
| Professional | | $1,637.27 | $1,867.17 | $2,296.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,143.56 / $2,186.69 / $2,296.04
| Facility | | $1,143.56 | $2,186.69 | $2,296.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,637.27 / $1,723.28 / $2,297.71
| Professional | | $1,637.27 | $1,723.28 | $2,297.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.86 / $1,023.29 / $1,576.86
| Professional | | $924.86 | $1,023.29 | $1,576.86 |