- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.09 / $1,578.68 / $5,898.26
| Professional | | $1,205.09 | $1,578.68 | $5,898.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,792.98 / $1,792.98 / $1,792.98
| Facility | | $1,792.98 | $1,792.98 | $1,792.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.82 / $1,792.98 / $1,882.19
| Professional | | $958.82 | $1,792.98 | $1,882.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $887.21 / $1,219.91 / $1,792.98
| Facility | | $887.21 | $1,219.91 | $1,792.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.02 / $1,792.98 / $2,347.80
| Professional | | $1,085.02 | $1,792.98 | $2,347.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,534.55 / $1,828.40 / $2,089.60
| Professional | | $1,534.55 | $1,828.40 | $2,089.60 |