- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.91 / $1,330.60 / $5,044.64
| Professional | | $1,066.91 | $1,330.60 | $5,044.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,535.34 / $1,535.34 / $1,535.34
| Facility | | $1,535.34 | $1,535.34 | $1,535.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.41 / $1,535.34 / $1,661.03
| Professional | | $812.41 | $1,535.34 | $1,661.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $757.20 / $824.20 / $1,535.34
| Facility | | $757.20 | $824.20 | $1,535.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.97 / $1,535.34 / $2,042.60
| Professional | | $943.97 | $1,535.34 | $2,042.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.54 / $1,655.31 / $1,828.86
| Professional | | $1,455.54 | $1,655.31 | $1,828.86 |