- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.08 / $6,734.35 / $6,734.35
| Professional | | $1,219.08 | $6,734.35 | $6,734.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,063.77 / $2,063.77 / $2,063.77
| Facility | | $2,063.77 | $2,063.77 | $2,063.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.07 / $2,063.77 / $2,172.61
| Professional | | $1,385.07 | $2,063.77 | $2,172.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.81 / $2,239.25 / $2,356.06
| Facility | | $1,020.81 | $2,239.25 | $2,356.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.83 / $1,883.93 / $2,717.40
| Professional | | $1,255.83 | $1,883.93 | $2,717.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.83 / $2,204.79 / $3,614.89
| Professional | | $1,772.83 | $2,204.79 | $3,614.89 |