- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.69 / $6,078.89 / $6,078.89
| Professional | | $1,349.69 | $6,078.89 | $6,078.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.13 / $1,857.13 / $1,857.13
| Facility | | $1,857.13 | $1,857.13 | $1,857.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.28 / $1,857.13 / $1,857.13
| Professional | | $1,486.28 | $1,857.13 | $1,857.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.13 / $2,371.85 / $2,432.60
| Facility | | $1,857.13 | $2,371.85 | $2,432.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.63 / $1,617.34 / $2,470.30
| Professional | | $1,141.63 | $1,617.34 | $2,470.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.05 / $2,101.21 / $3,249.53
| Professional | | $1,821.05 | $2,101.21 | $3,249.53 |