- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.64 / $1,565.44 / $5,854.24
| Professional | | $1,192.64 | $1,565.44 | $5,854.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,779.83 / $1,779.83 / $1,779.83
| Facility | | $1,779.83 | $1,779.83 | $1,779.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.44 / $1,779.83 / $1,888.59
| Professional | | $937.44 | $1,779.83 | $1,888.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $881.05 / $1,176.82 / $1,779.83
| Facility | | $881.05 | $1,176.82 | $1,779.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.33 / $1,779.83 / $2,324.69
| Professional | | $1,074.33 | $1,779.83 | $2,324.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.22 / $1,812.72 / $2,136.42
| Professional | | $1,470.22 | $1,812.72 | $2,136.42 |