- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.83 / $1,338.03 / $4,989.41
| Professional | | $1,018.83 | $1,338.03 | $4,989.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,519.04 / $1,519.04 / $1,519.04
| Facility | | $1,519.04 | $1,519.04 | $1,519.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.22 / $1,519.04 / $1,598.17
| Professional | | $655.22 | $1,519.04 | $1,598.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.48 / $1,034.66 / $1,519.04
| Facility | | $752.48 | $1,034.66 | $1,519.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.42 / $1,519.04 / $1,987.30
| Professional | | $918.42 | $1,519.04 | $1,987.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.70 / $1,543.92 / $2,371.02
| Professional | | $1,233.70 | $1,543.92 | $2,371.02 |