- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.89 / $6,284.21 / $6,284.21
| Professional | | $1,397.89 | $6,284.21 | $6,284.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,923.38 / $1,923.38 / $1,923.38
| Facility | | $1,923.38 | $1,923.38 | $1,923.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.42 / $1,923.38 / $1,923.38
| Professional | | $1,538.42 | $1,923.38 | $1,923.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,923.38 / $2,439.44 / $2,650.81
| Facility | | $1,923.38 | $2,439.44 | $2,650.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.04 / $1,676.00 / $2,559.90
| Professional | | $1,183.04 | $1,676.00 | $2,559.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.84 / $2,242.54 / $5,173.07
| Professional | | $1,880.84 | $2,242.54 | $5,173.07 |