- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.78 / $1,419.29 / $5,282.14
| Professional | | $1,079.78 | $1,419.29 | $5,282.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,612.63 / $1,612.63 / $1,612.63
| Facility | | $1,612.63 | $1,612.63 | $1,612.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.93 / $1,612.63 / $1,687.80
| Professional | | $771.93 | $1,612.63 | $1,687.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.99 / $1,098.60 / $1,612.63
| Facility | | $798.99 | $1,098.60 | $1,612.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.06 / $1,612.63 / $2,107.69
| Professional | | $974.06 | $1,612.63 | $2,107.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.30 / $1,661.54 / $1,865.59
| Professional | | $1,392.30 | $1,661.54 | $1,865.59 |