- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.34 / $5,352.85 / $5,352.85
| Professional | | $1,029.34 | $5,352.85 | $5,352.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.41 / $1,679.41 / $1,679.41
| Facility | | $1,679.41 | $1,679.41 | $1,679.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.31 / $1,679.41 / $1,683.57
| Professional | | $1,024.31 | $1,679.41 | $1,683.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $939.93 / $1,145.43 / $2,259.42
| Facility | | $939.93 | $1,145.43 | $2,259.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.85 / $1,666.27 / $2,055.17
| Professional | | $1,013.85 | $1,666.27 | $2,055.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.45 / $1,680.27 / $1,854.08
| Professional | | $1,506.45 | $1,680.27 | $1,854.08 |