- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.72 / $1,351.68 / $5,038.56
| Professional | | $1,029.72 | $1,351.68 | $5,038.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,534.28 / $1,534.28 / $1,534.28
| Facility | | $1,534.28 | $1,534.28 | $1,534.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.09 / $1,534.28 / $1,625.53
| Professional | | $828.09 | $1,534.28 | $1,625.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.46 / $1,044.26 / $1,573.34
| Facility | | $759.46 | $1,044.26 | $1,573.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.12 / $1,534.28 / $2,008.30
| Professional | | $928.12 | $1,534.28 | $2,008.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.35 / $1,586.87 / $1,781.75
| Professional | | $1,394.35 | $1,586.87 | $1,781.75 |