- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.54 / $6,064.54 / $6,064.54
| Professional | | $1,449.54 | $6,064.54 | $6,064.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.44 / $1,802.44 / $1,802.44
| Facility | | $1,802.44 | $1,802.44 | $1,802.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.39 / $1,802.44 / $1,927.00
| Professional | | $1,308.39 | $1,802.44 | $1,927.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.05 / $2,161.25 / $2,210.59
| Facility | | $891.05 | $2,161.25 | $2,210.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.93 / $1,632.06 / $2,354.10
| Professional | | $1,087.93 | $1,632.06 | $2,354.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.12 / $2,111.17 / $3,133.90
| Professional | | $1,732.12 | $2,111.17 | $3,133.90 |