- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.22 / $5,897.13 / $5,897.13
| Professional | | $1,700.22 | $5,897.13 | $5,897.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.82 / $2,373.62 / $2,373.62
| Facility | | $1,367.82 | $2,373.62 | $2,373.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.82 / $1,930.26 / $2,373.62
| Professional | | $1,367.82 | $1,930.26 | $2,373.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,139.51 / $2,260.59 / $2,373.62
| Facility | | $1,139.51 | $2,260.59 | $2,373.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.82 / $1,781.51 / $2,375.35
| Professional | | $1,367.82 | $1,781.51 | $2,375.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,536.34 / $1,536.34 / $1,614.49
| Facility | | $1,536.34 | $1,536.34 | $1,614.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.60 / $1,019.68 / $1,617.20
| Professional | | $921.60 | $1,019.68 | $1,617.20 |