- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.08 / $4,210.49 / $4,210.49
| Professional | | $1,055.08 | $4,210.49 | $4,210.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,342.89 / $1,342.89 / $1,342.89
| Facility | | $1,342.89 | $1,342.89 | $1,342.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.36 / $748.37 / $1,342.89
| Professional | | $748.36 | $748.37 | $1,342.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $726.40 / $957.60 / $1,342.89
| Facility | | $726.40 | $957.60 | $1,342.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.93 / $1,161.79 / $1,602.81
| Professional | | $812.93 | $1,161.79 | $1,602.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.00 / $1,490.00 / $1,490.00
| Facility | | $1,490.00 | $1,490.00 | $1,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.82 / $1,252.71 / $1,431.67
| Professional | | $1,124.82 | $1,252.71 | $1,431.67 |