- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.99 / $1,533.83 / $5,677.85
| Professional | | $1,235.99 | $1,533.83 | $5,677.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,830.31 / $1,830.31 / $1,830.31
| Facility | | $1,830.31 | $1,830.31 | $1,830.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.78 / $1,673.25 / $1,830.31
| Professional | | $834.78 | $1,673.25 | $1,830.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $903.45 / $1,129.31 / $1,812.11
| Facility | | $903.45 | $1,129.31 | $1,812.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.22 / $1,700.93 / $2,362.94
| Professional | | $1,072.22 | $1,700.93 | $2,362.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.01 / $1,776.49 / $2,047.16
| Professional | | $1,326.01 | $1,776.49 | $2,047.16 |