- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.25 / $6,032.42 / $6,032.42
| Professional | | $1,442.25 | $6,032.42 | $6,032.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,792.98 / $1,792.98 / $1,792.98
| Facility | | $1,792.98 | $1,792.98 | $1,792.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.86 / $1,792.98 / $1,917.11
| Professional | | $1,324.86 | $1,792.98 | $1,917.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.39 / $2,115.10 / $2,172.01
| Facility | | $886.39 | $2,115.10 | $2,172.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.43 / $1,623.81 / $2,342.19
| Professional | | $1,082.43 | $1,623.81 | $2,342.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.76 / $1,987.80 / $3,118.18
| Professional | | $1,722.76 | $1,987.80 | $3,118.18 |