- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.38 / $6,549.75 / $6,549.75
| Professional | | $1,295.38 | $6,549.75 | $6,549.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,958.08 / $1,958.08 / $1,958.08
| Facility | | $1,958.08 | $1,958.08 | $1,958.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.10 / $1,958.08 / $2,077.16
| Professional | | $1,411.10 | $1,958.08 | $2,077.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.29 / $2,200.90 / $2,317.48
| Facility | | $960.29 | $2,200.90 | $2,317.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.45 / $1,787.36 / $2,578.10
| Professional | | $1,191.45 | $1,787.36 | $2,578.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.87 / $2,144.07 / $3,431.76
| Professional | | $1,726.87 | $2,144.07 | $3,431.76 |