- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.63 / $6,012.65 / $6,012.65
| Professional | | $1,437.63 | $6,012.65 | $6,012.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.19 / $1,787.19 / $1,787.19
| Facility | | $1,787.19 | $1,787.19 | $1,787.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.78 / $1,787.19 / $1,910.12
| Professional | | $1,310.78 | $1,787.19 | $1,910.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $883.04 / $2,128.75 / $2,180.23
| Facility | | $883.04 | $2,128.75 | $2,180.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.86 / $1,618.48 / $2,334.50
| Professional | | $1,078.86 | $1,618.48 | $2,334.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.25 / $1,981.20 / $3,106.14
| Professional | | $1,670.25 | $1,981.20 | $3,106.14 |