- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.83 / $4,870.93 / $4,870.93
| Professional | | $1,165.83 | $4,870.93 | $4,870.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.73 / $1,451.73 / $1,451.73
| Facility | | $1,451.73 | $1,451.73 | $1,451.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.75 / $1,451.73 / $1,546.37
| Professional | | $1,067.75 | $1,451.73 | $1,546.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.98 / $1,722.50 / $1,764.04
| Facility | | $717.98 | $1,722.50 | $1,764.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.39 / $1,313.22 / $1,894.20
| Professional | | $875.39 | $1,313.22 | $1,894.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.50 / $1,656.64 / $2,522.46
| Professional | | $1,351.50 | $1,656.64 | $2,522.46 |