- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,288.25 / $2,754.23
| Professional | | $1,096.48 | $1,288.25 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,412.54 / $1,737.80
| Professional | | $691.83 | $1,412.54 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,344.23
| Facility | | $1,412.54 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,344.23
| Professional | | $1,412.54 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,737.80
| Facility | | $933.25 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,412.54 / $2,290.87
| Professional | | $79.43 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,737.80 / $2,089.30
| Professional | | $1,174.90 | $1,737.80 | $2,089.30 |