- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.54 / $1,457.23 / $5,459.77
| Professional | | $1,116.54 | $1,457.23 | $5,459.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.59 / $1,652.59 / $1,652.59
| Facility | | $1,652.59 | $1,652.59 | $1,652.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.59 / $1,652.59 / $1,763.46
| Professional | | $884.59 | $1,652.59 | $1,763.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.91 / $1,123.25 / $1,652.59
| Facility | | $816.91 | $1,123.25 | $1,652.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.82 / $1,652.59 / $2,172.10
| Professional | | $1,003.82 | $1,652.59 | $2,172.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.62 / $1,726.52 / $2,604.92
| Professional | | $1,423.62 | $1,726.52 | $2,604.92 |