- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.64 / $4,607.39 / $4,607.39
| Professional | | $1,011.64 | $4,607.39 | $4,607.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,409.14 / $1,409.14 / $1,409.14
| Facility | | $1,409.14 | $1,409.14 | $1,409.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.92 / $1,409.14 / $1,531.24
| Professional | | $1,013.92 | $1,409.14 | $1,531.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $694.28 / $1,628.25 / $1,702.06
| Facility | | $694.28 | $1,628.25 | $1,702.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.92 / $1,287.02 / $1,856.40
| Professional | | $857.92 | $1,287.02 | $1,856.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.56 / $1,532.82 / $2,460.50
| Professional | | $1,277.56 | $1,532.82 | $2,460.50 |