- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.38 / $6,081.63 / $6,081.63
| Professional | | $1,205.38 | $6,081.63 | $6,081.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,837.15 / $1,837.15 / $1,837.15
| Facility | | $1,837.15 | $1,837.15 | $1,837.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.16 / $1,837.15 / $1,958.43
| Professional | | $1,290.16 | $1,837.15 | $1,958.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.68 / $2,024.10 / $2,190.98
| Facility | | $898.68 | $2,024.10 | $2,190.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.93 / $1,681.56 / $2,425.50
| Professional | | $1,120.93 | $1,681.56 | $2,425.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,720.68 / $2,051.58 / $3,235.63
| Professional | | $1,720.68 | $2,051.58 | $3,235.63 |