- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.74 / $1,314.81 / $6,032.27
| Professional | | $1,087.74 | $1,314.81 | $6,032.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,867.64 / $1,867.64 / $1,867.64
| Facility | | $1,867.64 | $1,867.64 | $1,867.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.76 / $1,867.64 / $1,867.64
| Professional | | $1,199.76 | $1,867.64 | $1,867.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.27 / $1,903.85 / $2,073.96
| Facility | | $912.27 | $1,903.85 | $2,073.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.19 / $1,717.96 / $2,478.00
| Professional | | $1,145.19 | $1,717.96 | $2,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.07 / $1,903.85 / $3,296.70
| Professional | | $1,534.07 | $1,903.85 | $3,296.70 |