- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.14 / $1,443.75 / $5,420.33
| Professional | | $1,051.14 | $1,443.75 | $5,420.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.55 / $1,590.55 / $1,590.55
| Facility | | $1,590.55 | $1,590.55 | $1,590.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.78 / $1,590.55 / $1,729.70
| Professional | | $839.78 | $1,590.55 | $1,729.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.42 / $1,084.07 / $1,590.55
| Facility | | $788.42 | $1,084.07 | $1,590.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.35 / $1,590.55 / $2,087.40
| Professional | | $964.35 | $1,590.55 | $2,087.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.40 / $1,640.10 / $1,868.80
| Professional | | $1,372.40 | $1,640.10 | $1,868.80 |