- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.88 / $1,454.17 / $5,186.77
| Professional | | $1,104.88 | $1,454.17 | $5,186.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,641.55 / $1,641.55 / $1,641.55
| Facility | | $1,641.55 | $1,641.55 | $1,641.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.80 / $1,591.77 / $1,641.55
| Professional | | $798.80 | $1,591.77 | $1,641.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $805.32 / $1,107.32 / $1,641.55
| Facility | | $805.32 | $1,107.32 | $1,641.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.76 / $1,591.77 / $2,176.30
| Professional | | $1,005.76 | $1,591.77 | $2,176.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.57 / $1,575.83 / $2,031.12
| Professional | | $1,322.57 | $1,575.83 | $2,031.12 |