- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.86 / $1,421.35 / $5,463.96
| Professional | | $1,063.86 | $1,421.35 | $5,463.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,710.43 / $1,710.43 / $1,710.43
| Facility | | $1,710.43 | $1,710.43 | $1,710.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.18 / $1,710.43 / $1,812.35
| Professional | | $974.18 | $1,710.43 | $1,812.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.47 / $1,162.52 / $1,710.43
| Facility | | $845.47 | $1,162.52 | $1,710.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.88 / $1,706.57 / $2,300.71
| Professional | | $1,023.88 | $1,706.57 | $2,300.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.52 / $1,802.45 / $2,205.08
| Professional | | $1,530.52 | $1,802.45 | $2,205.08 |