- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.75 / $5,795.08 / $5,795.08
| Professional | | $1,384.75 | $5,795.08 | $5,795.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.47 / $1,721.47 / $1,721.47
| Facility | | $1,721.47 | $1,721.47 | $1,721.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.15 / $1,721.47 / $1,842.03
| Professional | | $1,266.15 | $1,721.47 | $1,842.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.27 / $2,113.15 / $2,194.14
| Facility | | $851.27 | $2,113.15 | $2,194.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.41 / $1,559.27 / $2,249.10
| Professional | | $1,039.41 | $1,559.27 | $2,249.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.16 / $1,885.58 / $2,997.01
| Professional | | $1,655.16 | $1,885.58 | $2,997.01 |