- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,781.89 / $9,648.82 / $9,648.82
| Professional | | $2,781.89 | $9,648.82 | $9,648.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.29 / $3,207.08 / $3,207.08
| Facility | | $1,808.29 | $3,207.08 | $3,207.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.29 / $3,207.08 / $3,207.08
| Professional | | $1,808.29 | $3,207.08 | $3,207.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.42 / $3,054.36 / $3,207.08
| Facility | | $1,613.42 | $3,054.36 | $3,207.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.05 / $2,460.40 / $3,343.13
| Professional | | $2,407.05 | $2,460.40 | $3,343.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.88 / $1,443.74 / $2,289.77
| Professional | | $1,304.88 | $1,443.74 | $2,289.77 |