- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.55 / $1,557.35 / $5,846.97
| Professional | | $1,217.55 | $1,557.35 | $5,846.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,790.35 / $1,790.35 / $1,790.35
| Facility | | $1,790.35 | $1,790.35 | $1,790.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.33 / $1,790.35 / $1,911.87
| Professional | | $966.33 | $1,790.35 | $1,911.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $885.02 / $1,216.90 / $1,790.35
| Facility | | $885.02 | $1,216.90 | $1,790.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.28 / $1,790.35 / $2,352.69
| Professional | | $1,087.28 | $1,790.35 | $2,352.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.22 / $1,899.49 / $2,075.67
| Professional | | $1,567.22 | $1,899.49 | $2,075.67 |