- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.40 / $6,513.64 / $6,513.64
| Professional | | $1,309.40 | $6,513.64 | $6,513.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,990.68 / $1,990.68 / $1,990.68
| Facility | | $1,990.68 | $1,990.68 | $1,990.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.33 / $1,990.68 / $2,064.94
| Professional | | $1,347.33 | $1,990.68 | $2,064.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.74 / $2,104.69 / $2,309.26
| Facility | | $975.74 | $2,104.69 | $2,309.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.77 / $1,837.35 / $2,650.20
| Professional | | $1,224.77 | $1,837.35 | $2,650.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.12 / $2,103.60 / $3,518.70
| Professional | | $1,823.12 | $2,103.60 | $3,518.70 |