- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.58 / $2,028.09 / $4,810.18
| Professional | | $1,190.58 | $2,028.09 | $4,810.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.46 / $1,517.46 / $1,517.46
| Facility | | $1,517.46 | $1,517.46 | $1,517.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.18 / $876.28 / $1,517.46
| Professional | | $863.18 | $876.28 | $1,517.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.13 / $1,049.80 / $1,517.46
| Facility | | $858.13 | $1,049.80 | $1,517.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.61 / $1,310.28 / $1,810.94
| Professional | | $916.61 | $1,310.28 | $1,810.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.08 / $1,490.00 / $7,542.00
| Facility | | $1,166.08 | $1,490.00 | $7,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.23 / $1,484.79 / $1,715.19
| Professional | | $1,267.23 | $1,484.79 | $1,715.19 |