- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.02 / $1,278.48 / $5,334.48
| Professional | | $1,042.02 | $1,278.48 | $5,334.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,592.65 / $1,592.65 / $1,592.65
| Facility | | $1,592.65 | $1,592.65 | $1,592.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.08 / $1,592.65 / $1,690.13
| Professional | | $1,148.08 | $1,592.65 | $1,690.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $787.24 / $1,873.30 / $1,960.12
| Facility | | $787.24 | $1,873.30 | $1,960.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.15 / $1,440.37 / $2,077.60
| Professional | | $960.15 | $1,440.37 | $2,077.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.48 / $1,754.40 / $2,766.68
| Professional | | $1,520.48 | $1,754.40 | $2,766.68 |