- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.27 / $5,736.76 / $5,736.76
| Professional | | $1,274.27 | $5,736.76 | $5,736.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,755.65 / $1,755.65 / $1,755.65
| Facility | | $1,755.65 | $1,755.65 | $1,755.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.46 / $1,755.65 / $1,755.65
| Professional | | $1,434.46 | $1,755.65 | $1,755.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,755.65 / $2,274.46 / $2,278.25
| Facility | | $1,755.65 | $2,274.46 | $2,278.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.86 / $1,528.43 / $2,334.50
| Professional | | $1,078.86 | $1,528.43 | $2,334.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.01 / $1,980.01 / $3,072.84
| Professional | | $1,716.01 | $1,980.01 | $3,072.84 |