- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.83 / $1,417.86 / $5,927.74
| Professional | | $1,164.83 | $1,417.86 | $5,927.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,761.96 / $1,761.96 / $1,761.96
| Facility | | $1,761.96 | $1,761.96 | $1,761.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.43 / $1,761.96 / $1,883.93
| Professional | | $1,313.43 | $1,761.96 | $1,883.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.65 / $2,080.65 / $2,175.80
| Facility | | $870.65 | $2,080.65 | $2,175.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.99 / $1,596.15 / $2,302.30
| Professional | | $1,063.99 | $1,596.15 | $2,302.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.51 / $1,953.01 / $3,064.51
| Professional | | $1,632.51 | $1,953.01 | $3,064.51 |