- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.22 / $1,376.06 / $1,376.06
| Professional | | $1,284.22 | $1,376.06 | $1,376.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,881.31 / $1,881.31 / $2,236.25
| Facility | | $1,881.31 | $1,881.31 | $2,236.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.11 / $1,693.18 / $1,881.31
| Professional | | $1,599.11 | $1,693.18 | $1,881.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.43 / $1,881.31 / $2,236.25
| Facility | | $759.43 | $1,881.31 | $2,236.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.11 / $1,881.31 / $2,647.74
| Professional | | $1,599.11 | $1,881.31 | $2,647.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.55 / $2,075.25 / $2,361.48
| Professional | | $1,538.55 | $2,075.25 | $2,361.48 |