- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.33 / $5,584.17 / $5,584.17
| Professional | | $1,120.33 | $5,584.17 | $5,584.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,694.65 / $1,694.65 / $1,694.65
| Facility | | $1,694.65 | $1,694.65 | $1,694.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.40 / $1,694.65 / $1,746.58
| Professional | | $1,189.40 | $1,694.65 | $1,746.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.46 / $1,862.90 / $1,962.65
| Facility | | $830.46 | $1,862.90 | $1,962.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.64 / $1,547.62 / $2,232.30
| Professional | | $1,031.64 | $1,547.62 | $2,232.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.66 / $1,834.24 / $2,971.10
| Professional | | $1,461.66 | $1,834.24 | $2,971.10 |