- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.41 / $6,671.26 / $6,671.26
| Professional | | $1,482.41 | $6,671.26 | $6,671.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.10 / $2,040.10 / $2,040.10
| Facility | | $2,040.10 | $2,040.10 | $2,040.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.69 / $2,040.10 / $2,040.10
| Professional | | $1,650.69 | $2,040.10 | $2,040.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.10 / $2,648.10 / $2,657.77
| Facility | | $2,040.10 | $2,648.10 | $2,657.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.21 / $1,776.83 / $2,713.90
| Professional | | $1,254.21 | $1,776.83 | $2,713.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,997.84 / $2,305.19 / $3,571.41
| Professional | | $1,997.84 | $2,305.19 | $3,571.41 |