- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.73 / $1,487.33 / $5,388.26
| Professional | | $1,138.73 | $1,487.33 | $5,388.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,693.60 / $1,693.60 / $1,693.60
| Facility | | $1,693.60 | $1,693.60 | $1,693.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.78 / $1,666.27 / $1,693.60
| Professional | | $827.78 | $1,666.27 | $1,693.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $835.54 / $1,148.85 / $1,693.60
| Facility | | $835.54 | $1,148.85 | $1,693.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.02 / $1,666.27 / $2,228.80
| Professional | | $1,030.02 | $1,666.27 | $2,228.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.72 / $1,652.48 / $1,875.41
| Professional | | $1,390.72 | $1,652.48 | $1,875.41 |