- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.98 / $6,276.04 / $6,276.04
| Professional | | $1,241.98 | $6,276.04 | $6,276.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,867.64 / $1,867.64 / $1,867.64
| Facility | | $1,867.64 | $1,867.64 | $1,867.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.13 / $1,867.64 / $1,992.77
| Professional | | $1,362.13 | $1,867.64 | $1,992.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.35 / $2,233.40 / $2,285.21
| Facility | | $923.35 | $2,233.40 | $2,285.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.72 / $1,691.76 / $2,440.19
| Professional | | $1,127.72 | $1,691.76 | $2,440.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.36 / $2,067.61 / $3,247.67
| Professional | | $1,752.36 | $2,067.61 | $3,247.67 |