- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.31 / $4,961.67 / $4,961.67
| Professional | | $1,003.31 | $4,961.67 | $4,961.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.46 / $1,517.46 / $1,517.46
| Facility | | $1,517.46 | $1,517.46 | $1,517.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.06 / $1,517.46 / $1,547.54
| Professional | | $1,046.06 | $1,517.46 | $1,547.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $744.20 / $1,680.90 / $1,769.10
| Facility | | $744.20 | $1,680.90 | $1,769.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.59 / $1,385.53 / $1,998.50
| Professional | | $923.59 | $1,385.53 | $1,998.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.86 / $1,616.61 / $2,661.21
| Professional | | $1,318.86 | $1,616.61 | $2,661.21 |