- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.88 / $4,779.46 / $4,779.46
| Professional | | $1,060.88 | $4,779.46 | $4,779.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.72 / $1,461.72 / $1,461.72
| Facility | | $1,461.72 | $1,461.72 | $1,461.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.50 / $1,461.72 / $1,461.72
| Professional | | $1,206.50 | $1,461.72 | $1,461.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,461.72 / $1,889.55 / $2,036.65
| Facility | | $1,461.72 | $1,889.55 | $2,036.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.36 / $1,272.70 / $1,943.90
| Professional | | $898.36 | $1,272.70 | $1,943.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.96 / $1,648.80 / $2,558.55
| Professional | | $1,428.96 | $1,648.80 | $2,558.55 |