- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.85 / $1,540.63 / $5,759.32
| Professional | | $1,173.85 | $1,540.63 | $5,759.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.97 / $1,751.97 / $1,751.97
| Facility | | $1,751.97 | $1,751.97 | $1,751.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.10 / $1,751.97 / $1,858.91
| Professional | | $924.10 | $1,751.97 | $1,858.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.38 / $1,192.64 / $1,751.97
| Facility | | $867.38 | $1,192.64 | $1,751.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.52 / $1,751.97 / $2,288.30
| Professional | | $1,057.52 | $1,751.97 | $2,288.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.00 / $1,808.04 / $2,037.11
| Professional | | $1,496.00 | $1,808.04 | $2,037.11 |