- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.69 / $6,725.69 / $6,725.69
| Professional | | $1,606.69 | $6,725.69 | $6,725.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,994.36 / $1,994.36 / $1,994.36
| Facility | | $1,994.36 | $1,994.36 | $1,994.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.37 / $1,994.36 / $2,138.27
| Professional | | $1,470.37 | $1,994.36 | $2,138.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $986.13 / $2,394.60 / $2,450.31
| Facility | | $986.13 | $2,394.60 | $2,450.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.68 / $1,808.71 / $2,608.90
| Professional | | $1,205.68 | $1,808.71 | $2,608.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.84 / $2,216.40 / $3,471.53
| Professional | | $1,878.84 | $2,216.40 | $3,471.53 |