- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.72 / $6,433.26 / $6,433.26
| Professional | | $1,403.72 | $6,433.26 | $6,433.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,948.61 / $1,948.61 / $1,948.61
| Facility | | $1,948.61 | $1,948.61 | $1,948.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.07 / $1,948.61 / $1,948.61
| Professional | | $1,430.07 | $1,948.61 | $1,948.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,948.61 / $2,296.44 / $2,321.91
| Facility | | $1,948.61 | $2,296.44 | $2,321.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.21 / $1,698.92 / $2,594.90
| Professional | | $1,199.21 | $1,698.92 | $2,594.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.83 / $2,261.12 / $3,421.58
| Professional | | $1,801.83 | $2,261.12 | $3,421.58 |