- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.30 / $4,754.71 / $4,754.71
| Professional | | $1,136.30 | $4,754.71 | $4,754.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,414.40 / $1,414.40 / $1,414.40
| Facility | | $1,414.40 | $1,414.40 | $1,414.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.02 / $1,414.40 / $1,510.87
| Professional | | $1,033.02 | $1,414.40 | $1,510.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.37 / $1,687.40 / $1,728.62
| Facility | | $699.37 | $1,687.40 | $1,728.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.07 / $1,279.74 / $1,845.90
| Professional | | $853.07 | $1,279.74 | $1,845.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.96 / $1,566.00 / $2,459.57
| Professional | | $1,323.96 | $1,566.00 | $2,459.57 |