- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.13 / $1,509.84 / $5,888.30
| Professional | | $1,138.13 | $1,509.84 | $5,888.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,979.64 / $1,979.64 / $1,979.64
| Facility | | $1,979.64 | $1,979.64 | $1,979.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.50 / $1,929.77 / $1,979.64
| Professional | | $1,013.50 | $1,929.77 | $1,979.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.30 / $1,220.46 / $1,979.64
| Facility | | $957.30 | $1,220.46 | $1,979.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.61 / $1,819.26 / $2,364.31
| Professional | | $1,114.61 | $1,819.26 | $2,364.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.65 / $1,856.40 / $2,177.98
| Professional | | $1,690.65 | $1,856.40 | $2,177.98 |