- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.09 / $1,545.18 / $5,796.67
| Professional | | $1,179.09 | $1,545.18 | $5,796.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,755.12 / $1,755.12 / $1,755.12
| Facility | | $1,755.12 | $1,755.12 | $1,755.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.17 / $1,421.83 / $1,755.12
| Professional | | $692.17 | $1,421.83 | $1,755.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.06 / $929.90 / $1,554.05
| Facility | | $732.06 | $929.90 | $1,554.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.63 / $1,652.33 / $2,296.00
| Professional | | $1,016.63 | $1,652.33 | $2,296.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.68 / $1,766.05 / $2,317.67
| Professional | | $1,292.68 | $1,766.05 | $2,317.67 |