- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.19 / $5,039.01 / $5,039.01
| Professional | | $1,097.19 | $5,039.01 | $5,039.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,533.23 / $1,533.23 / $1,533.23
| Facility | | $1,533.23 | $1,533.23 | $1,533.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.17 / $1,533.23 / $1,533.23
| Professional | | $1,153.17 | $1,533.23 | $1,533.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,533.23 / $1,805.05 / $1,877.89
| Facility | | $1,533.23 | $1,805.05 | $1,877.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.86 / $1,327.24 / $2,027.20
| Professional | | $936.86 | $1,327.24 | $2,027.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.27 / $1,713.00 / $2,682.50
| Professional | | $1,416.27 | $1,713.00 | $2,682.50 |