- 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
- $1,320.52 / $1,802.44 / $1,927.00
| Professional | | $1,320.52 | $1,802.44 | $1,927.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.05 / $2,106.65 / $2,168.21
| Facility | | $891.05 | $2,106.65 | $2,168.21 |
- 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
- $1,652.91 / $1,965.28 / $3,133.90
| Professional | | $1,652.91 | $1,965.28 | $3,133.90 |