- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.56 / $1,757.60 / $6,577.63
| Professional | | $1,329.56 | $1,757.60 | $6,577.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,991.73 / $1,991.73 / $1,991.73
| Facility | | $1,991.73 | $1,991.73 | $1,991.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.26 / $1,991.73 / $2,113.23
| Professional | | $505.26 | $1,991.73 | $2,113.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $705.53 / $986.09 / $1,355.87
| Facility | | $705.53 | $986.09 | $1,355.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.76 / $1,991.73 / $2,594.90
| Professional | | $1,153.76 | $1,991.73 | $2,594.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.42 / $2,035.04 / $2,403.05
| Professional | | $957.42 | $2,035.04 | $2,403.05 |