- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.67 / $5,878.84 / $5,878.84
| Professional | | $1,283.67 | $5,878.84 | $5,878.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.25 / $1,788.25 / $1,788.25
| Facility | | $1,788.25 | $1,788.25 | $1,788.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.50 / $1,788.25 / $1,788.25
| Professional | | $1,361.50 | $1,788.25 | $1,788.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,788.25 / $2,101.44 / $2,188.44
| Facility | | $1,788.25 | $2,101.44 | $2,188.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.69 / $1,552.26 / $2,370.90
| Professional | | $1,095.69 | $1,552.26 | $2,370.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.83 / $2,066.46 / $4,786.31
| Professional | | $1,648.83 | $2,066.46 | $4,786.31 |