- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.31 / $5,311.29 / $5,311.29
| Professional | | $1,531.31 | $5,311.29 | $5,311.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.56 / $2,002.08 / $2,002.08
| Facility | | $1,329.56 | $2,002.08 | $2,002.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.56 / $2,002.08 / $2,002.08
| Professional | | $1,329.56 | $2,002.08 | $2,002.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.56 / $1,906.74 / $2,002.08
| Facility | | $1,329.56 | $1,906.74 | $2,002.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.87 / $1,535.94 / $2,003.52
| Professional | | $1,482.87 | $1,535.94 | $2,003.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.70 / $840.55 / $1,333.11
| Professional | | $759.70 | $840.55 | $1,333.11 |