- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,288.25 / $6,760.83
| Professional | | $1,122.02 | $1,288.25 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.24 / $1,621.81 / $2,089.30
| Facility | | $2.24 | $1,621.81 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $2,137.96
| Professional | | $1,288.25 | $1,548.82 | $2,137.96 |