- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.22 / $5,377.25 / $5,377.25
| Professional | | $1,173.22 | $5,377.25 | $5,377.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,663.11 / $1,663.11 / $1,663.11
| Facility | | $1,663.11 | $1,663.11 | $1,663.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.71 / $1,663.11 / $1,663.11
| Professional | | $1,212.71 | $1,663.11 | $1,663.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,663.11 / $1,951.30 / $2,032.22
| Facility | | $1,663.11 | $1,951.30 | $2,032.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.17 / $1,421.19 / $2,170.69
| Professional | | $1,003.17 | $1,421.19 | $2,170.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.01 / $1,827.00 / $2,912.83
| Professional | | $1,531.01 | $1,827.00 | $2,912.83 |