- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.83 / $6,171.61 / $6,171.61
| Professional | | $1,310.83 | $6,171.61 | $6,171.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,801.39 / $1,801.39 / $1,801.39
| Facility | | $1,801.39 | $1,801.39 | $1,801.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.24 / $1,801.39 / $1,801.39
| Professional | | $1,446.24 | $1,801.39 | $1,801.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,801.39 / $2,332.85 / $2,416.78
| Facility | | $1,801.39 | $2,332.85 | $2,416.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.63 / $1,570.59 / $2,398.90
| Professional | | $1,108.63 | $1,570.59 | $2,398.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.39 / $2,087.42 / $3,154.24
| Professional | | $1,830.39 | $2,087.42 | $3,154.24 |