- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.70 / $6,582.10 / $6,582.10
| Professional | | $1,897.70 | $6,582.10 | $6,582.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $2,683.87 / $2,683.87
| Facility | | $1,747.16 | $2,683.87 | $2,683.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.16 / $2,182.54 / $2,683.87
| Professional | | $1,747.16 | $2,182.54 | $2,683.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.32 / $2,556.07 / $2,683.87
| Facility | | $1,260.32 | $2,556.07 | $2,683.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.16 / $2,014.36 / $2,685.82
| Professional | | $1,747.16 | $2,014.36 | $2,685.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.30 / $1,127.77 / $1,737.86
| Professional | | $1,019.30 | $1,127.77 | $1,737.86 |