- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.16 / $4,773.78 / $4,773.78
| Professional | | $1,060.16 | $4,773.78 | $4,773.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,459.62 / $1,459.62 / $1,459.62
| Facility | | $1,459.62 | $1,459.62 | $1,459.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.72 / $1,459.62 / $1,459.62
| Professional | | $1,201.72 | $1,459.62 | $1,459.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,459.62 / $1,863.55 / $1,912.05
| Facility | | $1,459.62 | $1,863.55 | $1,912.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.71 / $1,271.78 / $1,942.50
| Professional | | $897.71 | $1,271.78 | $1,942.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.40 / $1,647.00 / $2,556.69
| Professional | | $1,427.40 | $1,647.00 | $2,556.69 |