- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.32 / $1,309.78 / $6,759.10
| Professional | | $1,141.32 | $1,309.78 | $6,759.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,904.45 / $1,904.45 / $1,904.45
| Facility | | $1,904.45 | $1,904.45 | $1,904.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.28 / $1,904.45 / $2,226.73
| Professional | | $1,086.28 | $1,904.45 | $2,226.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $946.09 / $1,300.86 / $1,904.45
| Facility | | $946.09 | $1,300.86 | $1,904.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.69 / $1,904.45 / $2,613.63
| Professional | | $1,194.69 | $1,904.45 | $2,613.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.27 / $2,131.48 / $2,531.09
| Professional | | $1,747.27 | $2,131.48 | $2,531.09 |