- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.93 / $5,653.45 / $5,653.45
| Professional | | $1,351.93 | $5,653.45 | $5,653.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,680.98 / $1,680.98 / $1,680.98
| Facility | | $1,680.98 | $1,680.98 | $1,680.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.84 / $1,680.98 / $1,873.46
| Professional | | $1,259.84 | $1,680.98 | $1,873.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.38 / $2,091.05 / $2,163.78
| Facility | | $831.38 | $2,091.05 | $2,163.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.82 / $1,522.39 / $2,195.90
| Professional | | $1,014.82 | $1,522.39 | $2,195.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.08 / $1,865.86 / $2,923.91
| Professional | | $1,614.08 | $1,865.86 | $2,923.91 |