- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.57 / $1,084.54 / $5,326.91
| Professional | | $1,051.57 | $1,084.54 | $5,326.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,582.66 / $1,582.66 / $1,582.66
| Facility | | $1,582.66 | $1,582.66 | $1,582.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.19 / $1,582.66 / $1,709.33
| Professional | | $1,153.19 | $1,582.66 | $1,709.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $782.82 / $1,902.55 / $2,155.56
| Facility | | $782.82 | $1,902.55 | $2,155.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.30 / $1,433.09 / $2,067.10
| Professional | | $955.30 | $1,433.09 | $2,067.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.44 / $1,873.28 / $2,750.03
| Professional | | $1,519.44 | $1,873.28 | $2,750.03 |