- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.58 / $6,484.36 / $6,484.36
| Professional | | $1,284.58 | $6,484.36 | $6,484.36 |
- 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
- $1,376.51 / $1,958.08 / $2,082.40
| Professional | | $1,376.51 | $1,958.08 | $2,082.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.36 / $2,156.05 / $2,335.82
| Facility | | $957.36 | $2,156.05 | $2,335.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.33 / $1,793.18 / $2,586.50
| Professional | | $1,195.33 | $1,793.18 | $2,586.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,691.66 / $2,115.60 / $3,450.24
| Professional | | $1,691.66 | $2,115.60 | $3,450.24 |