- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.80 / $6,394.42 / $6,394.42
| Professional | | $1,379.80 | $6,394.42 | $6,394.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.56 / $1,947.56 / $1,947.56
| Facility | | $1,947.56 | $1,947.56 | $1,947.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.23 / $1,947.56 / $1,947.56
| Professional | | $1,140.23 | $1,947.56 | $1,947.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $951.67 / $1,893.07 / $1,947.56
| Facility | | $951.67 | $1,893.07 | $1,947.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.07 / $1,705.79 / $2,605.40
| Professional | | $1,204.07 | $1,705.79 | $2,605.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.31 / $2,026.07 / $3,448.38
| Professional | | $1,545.31 | $2,026.07 | $3,448.38 |