- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.83 / $5,649.81 / $5,649.81
| Professional | | $1,254.83 | $5,649.81 | $5,649.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.68 / $1,725.68 / $1,725.68
| Facility | | $1,725.68 | $1,725.68 | $1,725.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.74 / $1,725.68 / $1,725.68
| Professional | | $1,414.74 | $1,725.68 | $1,725.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.68 / $2,282.15 / $2,435.13
| Facility | | $1,725.68 | $2,282.15 | $2,435.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.40 / $1,503.68 / $2,296.69
| Professional | | $1,061.40 | $1,503.68 | $2,296.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,692.61 / $1,953.01 / $3,021.06
| Professional | | $1,692.61 | $1,953.01 | $3,021.06 |