- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.25 / $1,156.67 / $5,857.58
| Professional | | $926.25 | $1,156.67 | $5,857.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,719.37 / $1,719.37 / $1,719.37
| Facility | | $1,719.37 | $1,719.37 | $1,719.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.63 / $1,719.37 / $1,882.77
| Professional | | $885.63 | $1,719.37 | $1,882.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.57 / $1,169.53 / $1,719.37
| Facility | | $850.57 | $1,169.53 | $1,719.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.49 / $1,719.37 / $2,266.60
| Professional | | $1,047.49 | $1,719.37 | $2,266.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.79 / $1,764.39 / $2,033.22
| Professional | | $1,453.79 | $1,764.39 | $2,033.22 |