- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.97 / $1,473.58 / $5,496.28
| Professional | | $1,119.97 | $1,473.58 | $5,496.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.72 / $1,675.72 / $1,675.72
| Facility | | $1,675.72 | $1,675.72 | $1,675.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.24 / $1,675.72 / $1,765.79
| Professional | | $878.24 | $1,675.72 | $1,765.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $830.50 / $1,141.94 / $1,675.72
| Facility | | $830.50 | $1,141.94 | $1,675.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.29 / $1,675.72 / $2,186.10
| Professional | | $1,010.29 | $1,675.72 | $2,186.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.51 / $1,711.71 / $1,941.12
| Professional | | $1,425.51 | $1,711.71 | $1,941.12 |