- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.31 / $5,026.96 / $5,026.96
| Professional | | $1,216.31 | $5,026.96 | $5,026.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.23 / $1,482.23 / $1,482.23
| Facility | | $1,482.23 | $1,482.23 | $1,482.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.35 / $1,482.23 / $1,595.84
| Professional | | $1,079.35 | $1,482.23 | $1,595.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.22 / $1,768.00 / $1,819.70
| Facility | | $733.22 | $1,768.00 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.01 / $1,365.15 / $1,969.10
| Professional | | $910.01 | $1,365.15 | $1,969.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.20 / $1,633.71 / $2,625.15
| Professional | | $1,387.20 | $1,633.71 | $2,625.15 |