- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.29 / $6,150.35 / $6,150.35
| Professional | | $1,248.29 | $6,150.35 | $6,150.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,974.38 / $1,974.38 / $1,974.38
| Facility | | $1,974.38 | $1,974.38 | $1,974.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.94 / $1,974.38 / $2,109.75
| Professional | | $1,218.94 | $1,974.38 | $2,109.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.31 / $2,055.30 / $2,215.65
| Facility | | $974.31 | $2,055.30 | $2,215.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.78 / $1,771.35 / $2,555.00
| Professional | | $1,180.78 | $1,771.35 | $2,555.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.34 / $2,055.30 / $3,436.37
| Professional | | $1,655.34 | $2,055.30 | $3,436.37 |