- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.97 / $1,656.46 / $6,180.88
| Professional | | $1,186.97 | $1,656.46 | $6,180.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,781.94 / $1,781.94 / $1,781.94
| Facility | | $1,781.94 | $1,781.94 | $1,781.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.73 / $1,781.94 / $1,794.31
| Professional | | $859.73 | $1,781.94 | $1,794.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $882.42 / $1,213.32 / $1,781.94
| Facility | | $882.42 | $1,213.32 | $1,781.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.67 / $1,781.94 / $2,373.00
| Professional | | $1,096.67 | $1,781.94 | $2,373.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.94 / $1,849.12 / $2,113.28
| Professional | | $1,551.94 | $1,849.12 | $2,113.28 |