- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.23 / $1,451.97 / $5,075.47
| Professional | | $1,085.23 | $1,451.97 | $5,075.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.78 / $1,615.78 / $1,615.78
| Facility | | $1,615.78 | $1,615.78 | $1,615.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.19 / $1,494.22 / $1,615.78
| Professional | | $781.19 | $1,494.22 | $1,615.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.43 / $1,049.65 / $1,615.78
| Facility | | $784.43 | $1,049.65 | $1,615.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.12 / $1,494.22 / $2,151.10
| Professional | | $994.12 | $1,494.22 | $2,151.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.80 / $1,534.40 / $1,736.62
| Professional | | $1,287.80 | $1,534.40 | $1,736.62 |