- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.12 / $1,010.12 / $5,294.19
| Professional | | $1,010.12 | $1,010.12 | $5,294.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,623.14 / $1,623.14 / $1,623.14
| Facility | | $1,623.14 | $1,623.14 | $1,623.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.01 / $1,623.14 / $1,694.78
| Professional | | $1,079.01 | $1,623.14 | $1,694.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.59 / $1,736.80 / $1,859.55
| Facility | | $800.59 | $1,736.80 | $1,859.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.79 / $1,490.84 / $2,150.40
| Professional | | $993.79 | $1,490.84 | $2,150.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.94 / $1,736.79 / $2,842.51
| Professional | | $1,402.94 | $1,736.79 | $2,842.51 |