- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.12 / $5,517.54
| Professional | | $1,122.02 | $1,479.12 | $5,517.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,667.31 / $1,667.31 / $1,667.31
| Facility | | $1,667.31 | $1,667.31 | $1,667.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.32 / $1,667.31 / $1,766.37
| Professional | | $898.32 | $1,667.31 | $1,766.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.06 / $1,038.82 / $2,001.23
| Facility | | $831.06 | $1,038.82 | $2,001.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.20 / $1,667.31 / $2,192.40
| Professional | | $1,013.20 | $1,667.31 | $2,192.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.31 / $1,732.22 / $1,991.87
| Professional | | $1,469.31 | $1,732.22 | $1,991.87 |