- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.21 / $4,191.37 / $4,191.37
| Professional | | $1,002.21 | $4,191.37 | $4,191.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.25 / $1,248.25 / $1,248.25
| Facility | | $1,248.25 | $1,248.25 | $1,248.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.38 / $1,248.25 / $1,328.71
| Professional | | $912.38 | $1,248.25 | $1,328.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $617.74 / $1,480.05 / $1,518.63
| Facility | | $617.74 | $1,480.05 | $1,518.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.78 / $1,129.29 / $1,628.90
| Professional | | $752.78 | $1,129.29 | $1,628.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.28 / $1,378.80 / $2,170.04
| Professional | | $1,161.28 | $1,378.80 | $2,170.04 |