- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.25 / $1,221.36 / $6,076.50
| Professional | | $1,165.25 | $1,221.36 | $6,076.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.08 / $1,846.08 / $1,846.08
| Facility | | $1,846.08 | $1,846.08 | $1,846.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.62 / $1,846.08 / $1,890.92
| Professional | | $1,315.62 | $1,846.08 | $1,890.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.81 / $2,026.70 / $2,129.63
| Facility | | $903.81 | $2,026.70 | $2,129.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.81 / $1,687.39 / $2,433.90
| Professional | | $1,124.81 | $1,687.39 | $2,433.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.18 / $1,995.52 / $3,237.49
| Professional | | $1,590.18 | $1,995.52 | $3,237.49 |