- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.17 / $6,776.54 / $6,776.54
| Professional | | $1,493.17 | $6,776.54 | $6,776.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,063.23 / $2,063.23 / $2,063.23
| Facility | | $2,063.23 | $2,063.23 | $2,063.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.78 / $2,063.23 / $2,262.82
| Professional | | $1,516.78 | $2,063.23 | $2,262.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.51 / $2,421.90 / $2,518.62
| Facility | | $1,015.51 | $2,421.90 | $2,518.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.30 / $1,893.64 / $2,731.40
| Professional | | $1,262.30 | $1,893.64 | $2,731.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.25 / $2,306.39 / $3,614.89
| Professional | | $1,900.25 | $2,306.39 | $3,614.89 |