- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,437.13 / $5,365.10
| Professional | | $1,094.72 | $1,437.13 | $5,365.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,633.66 / $1,633.66 / $1,633.66
| Facility | | $1,633.66 | $1,633.66 | $1,633.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.78 / $1,633.66 / $1,723.30
| Professional | | $857.78 | $1,633.66 | $1,723.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $808.25 / $1,111.33 / $1,633.66
| Facility | | $808.25 | $1,111.33 | $1,633.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.68 / $1,633.66 / $2,135.00
| Professional | | $986.68 | $1,633.66 | $2,135.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.66 / $1,690.62 / $1,898.24
| Professional | | $1,512.66 | $1,690.62 | $1,898.24 |