- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.64 / $6,646.11 / $6,646.11
| Professional | | $1,366.64 | $6,646.11 | $6,646.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,971.75 / $1,971.75 / $1,971.75
| Facility | | $1,971.75 | $1,971.75 | $1,971.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.79 / $1,971.75 / $1,971.75
| Professional | | $1,486.79 | $1,971.75 | $1,971.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,971.75 / $2,526.55 / $2,620.44
| Facility | | $1,971.75 | $2,526.55 | $2,620.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.07 / $1,690.21 / $2,581.60
| Professional | | $1,193.07 | $1,690.21 | $2,581.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.43 / $2,264.23 / $3,432.66
| Professional | | $1,716.43 | $2,264.23 | $3,432.66 |