- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.20 / $1,578.34 / $6,587.44
| Professional | | $1,277.20 | $1,578.34 | $6,587.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,964.91 / $1,964.91 / $1,964.91
| Facility | | $1,964.91 | $1,964.91 | $1,964.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.82 / $1,964.91 / $2,085.31
| Professional | | $1,421.82 | $1,964.91 | $2,085.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $972.46 / $2,325.05 / $2,384.53
| Facility | | $972.46 | $2,325.05 | $2,384.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.30 / $1,778.14 / $2,564.80
| Professional | | $1,185.30 | $1,778.14 | $2,564.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,824.27 / $2,167.81 / $3,415.11
| Professional | | $1,824.27 | $2,167.81 | $3,415.11 |