- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,703.84 / $9,378.12 / $9,378.12
| Professional | | $2,703.84 | $9,378.12 | $9,378.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,523.27 / $2,559.67 / $2,559.67
| Facility | | $1,523.27 | $2,559.67 | $2,559.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.27 / $2,081.55 / $2,559.67
| Professional | | $1,523.27 | $2,081.55 | $2,559.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,359.12 / $2,437.79 / $2,559.67
| Facility | | $1,359.12 | $2,437.79 | $2,559.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.27 / $1,921.15 / $2,561.53
| Professional | | $1,523.27 | $1,921.15 | $2,561.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.21 / $1,216.18 / $1,874.10
| Professional | | $1,099.21 | $1,216.18 | $1,874.10 |