- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.48 / $1,363.32 / $5,082.93
| Professional | | $1,037.48 | $1,363.32 | $5,082.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.96 / $1,547.96 / $1,547.96
| Facility | | $1,547.96 | $1,547.96 | $1,547.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.86 / $1,547.96 / $1,630.18
| Professional | | $811.86 | $1,547.96 | $1,630.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.17 / $1,053.48 / $1,547.96
| Facility | | $766.17 | $1,053.48 | $1,547.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.24 / $1,547.96 / $2,023.70
| Professional | | $935.24 | $1,547.96 | $2,023.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.76 / $1,572.48 / $1,797.12
| Professional | | $1,319.76 | $1,572.48 | $1,797.12 |