- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.02 / $6,448.80 / $6,448.80
| Professional | | $1,407.02 | $6,448.80 | $6,448.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.23 / $1,961.23 / $1,961.23
| Facility | | $1,961.23 | $1,961.23 | $1,961.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.52 / $1,961.23 / $1,961.23
| Professional | | $1,433.52 | $1,961.23 | $1,961.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.23 / $2,617.92 / $2,664.35
| Facility | | $1,961.23 | $2,617.92 | $2,664.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.16 / $1,701.67 / $2,599.10
| Professional | | $1,201.16 | $1,701.67 | $2,599.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.60 / $2,192.98 / $5,504.41
| Professional | | $1,900.60 | $2,192.98 | $5,504.41 |