- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.25 / $1,305.92 / $5,481.44
| Professional | | $1,105.25 | $1,305.92 | $5,481.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.72 / $1,624.72 / $1,624.72
| Facility | | $1,624.72 | $1,624.72 | $1,624.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.63 / $1,624.72 / $1,743.67
| Professional | | $1,196.63 | $1,624.72 | $1,743.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.48 / $1,944.80 / $1,996.17
| Facility | | $803.48 | $1,944.80 | $1,996.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.53 / $1,470.94 / $2,121.69
| Professional | | $980.53 | $1,470.94 | $2,121.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.92 / $1,777.08 / $2,826.79
| Professional | | $1,525.92 | $1,777.08 | $2,826.79 |