- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.21 / $1,324.36 / $4,936.03
| Professional | | $1,009.21 | $1,324.36 | $4,936.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,504.31 / $1,504.31 / $1,504.31
| Facility | | $1,504.31 | $1,504.31 | $1,504.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.42 / $1,504.31 / $1,581.88
| Professional | | $734.42 | $1,504.31 | $1,581.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.26 / $1,024.73 / $1,504.31
| Facility | | $745.26 | $1,024.73 | $1,504.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.68 / $1,504.31 / $1,968.40
| Professional | | $909.68 | $1,504.31 | $1,968.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,228.54 / $1,499.29 / $1,727.73
| Professional | | $1,228.54 | $1,499.29 | $1,727.73 |