- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.40 / $4,870.93 / $4,870.93
| Professional | | $1,164.40 | $4,870.93 | $4,870.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,446.48 / $1,446.48 / $1,446.48
| Facility | | $1,446.48 | $1,446.48 | $1,446.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.61 / $1,446.48 / $1,548.12
| Professional | | $1,041.61 | $1,446.48 | $1,548.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $715.42 / $1,714.70 / $1,764.68
| Facility | | $715.42 | $1,714.70 | $1,764.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.10 / $1,311.28 / $1,891.40
| Professional | | $874.10 | $1,311.28 | $1,891.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.38 / $1,605.01 / $2,527.10
| Professional | | $1,345.38 | $1,605.01 | $2,527.10 |