- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $6,678.71 / $6,678.71
| Professional | | $1,925.56 | $6,678.71 | $6,678.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,349.13 / $1,988.22 / $1,988.22
| Facility | | $1,349.13 | $1,988.22 | $1,988.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.13 / $1,988.22 / $1,988.22
| Professional | | $1,349.13 | $1,988.22 | $1,988.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.04 / $1,893.54 / $1,988.22
| Facility | | $1,010.04 | $1,893.54 | $1,988.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.25 / $1,525.32 / $2,110.00
| Professional | | $1,492.25 | $1,525.32 | $2,110.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.88 / $903.82 / $1,392.75
| Professional | | $816.88 | $903.82 | $1,392.75 |