- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.72 / $6,149.45 / $6,149.45
| Professional | | $1,366.72 | $6,149.45 | $6,149.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.21 / $1,879.21 / $1,879.21
| Facility | | $1,879.21 | $1,879.21 | $1,879.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.34 / $1,879.21 / $1,879.21
| Professional | | $1,404.34 | $1,879.21 | $1,879.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.21 / $2,353.65 / $2,424.37
| Facility | | $1,879.21 | $2,353.65 | $2,424.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.86 / $1,637.51 / $2,501.10
| Professional | | $1,155.86 | $1,637.51 | $2,501.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.36 / $2,125.79 / $3,290.23
| Professional | | $1,842.36 | $2,125.79 | $3,290.23 |