- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.26 / $7,749.41 / $7,749.41
| Professional | | $2,234.26 | $7,749.41 | $7,749.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $2,781.94 / $2,781.94
| Facility | | $1,482.94 | $2,781.94 | $2,781.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.94 / $2,781.94 / $2,781.94
| Professional | | $1,482.94 | $2,781.94 | $2,781.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.14 / $2,649.47 / $2,781.94
| Facility | | $1,323.14 | $2,649.47 | $2,781.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.94 / $2,087.96 / $2,783.95
| Professional | | $1,482.94 | $2,087.96 | $2,783.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.10 / $1,183.99 / $1,824.48
| Professional | | $1,070.10 | $1,183.99 | $1,824.48 |