- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.91 / $6,258.07 / $6,258.07
| Professional | | $1,218.91 | $6,258.07 | $6,258.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,934.94 / $1,934.94 / $1,934.94
| Facility | | $1,934.94 | $1,934.94 | $1,934.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.22 / $1,934.94 / $2,003.83
| Professional | | $1,186.22 | $1,934.94 | $2,003.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.83 / $1,986.40 / $2,129.63
| Facility | | $954.83 | $1,986.40 | $2,129.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.35 / $1,775.23 / $2,560.60
| Professional | | $1,183.35 | $1,775.23 | $2,560.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,649.22 / $2,035.21 / $3,383.63
| Professional | | $1,649.22 | $2,035.21 | $3,383.63 |