- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.52 / $1,490.58 / $5,574.01
| Professional | | $1,133.52 | $1,490.58 | $5,574.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,694.65 / $1,694.65 / $1,694.65
| Facility | | $1,694.65 | $1,694.65 | $1,694.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.70 / $1,694.65 / $1,797.80
| Professional | | $623.70 | $1,694.65 | $1,797.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $664.96 / $839.24 / $1,694.65
| Facility | | $664.96 | $839.24 | $1,694.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.86 / $1,694.65 / $2,210.60
| Professional | | $984.86 | $1,694.65 | $2,210.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.77 / $1,732.09 / $2,223.12
| Professional | | $1,444.77 | $1,732.09 | $2,223.12 |