- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.29 / $1,415.54 / $5,331.84
| Professional | | $1,070.29 | $1,415.54 | $5,331.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,589.49 / $1,589.49 / $1,589.49
| Facility | | $1,589.49 | $1,589.49 | $1,589.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.06 / $1,589.49 / $1,686.64
| Professional | | $826.06 | $1,589.49 | $1,686.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $785.40 / $1,029.72 / $1,589.49
| Facility | | $785.40 | $1,029.72 | $1,589.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.59 / $1,589.49 / $2,093.69
| Professional | | $967.59 | $1,589.49 | $2,093.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.26 / $1,642.48 / $1,858.93
| Professional | | $1,448.26 | $1,642.48 | $1,858.93 |