- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.04 / $1,404.38 / $5,238.91
| Professional | | $1,070.04 | $1,404.38 | $5,238.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,594.75 / $1,594.75 / $1,594.75
| Facility | | $1,594.75 | $1,594.75 | $1,594.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.06 / $1,594.75 / $1,681.40
| Professional | | $836.06 | $1,594.75 | $1,681.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.18 / $1,086.49 / $1,594.75
| Facility | | $790.18 | $1,086.49 | $1,594.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.35 / $1,594.75 / $2,086.69
| Professional | | $964.35 | $1,594.75 | $2,086.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.64 / $1,644.29 / $1,910.69
| Professional | | $1,360.64 | $1,644.29 | $1,910.69 |