- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.27 / $1,482.37 / $5,735.22
| Professional | | $1,066.27 | $1,482.37 | $5,735.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,713.58 / $1,713.58 / $1,713.58
| Facility | | $1,713.58 | $1,713.58 | $1,713.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.10 / $1,713.58 / $1,861.24
| Professional | | $951.10 | $1,713.58 | $1,861.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $839.70 / $1,154.58 / $1,713.58
| Facility | | $839.70 | $1,154.58 | $1,713.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.29 / $1,713.58 / $2,280.60
| Professional | | $1,043.29 | $1,713.58 | $2,280.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.17 / $1,814.81 / $2,002.55
| Professional | | $1,539.17 | $1,814.81 | $2,002.55 |