- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.95 / $1,741.43 / $6,526.14
| Professional | | $1,329.95 | $1,741.43 | $6,526.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,976.48 / $1,976.48 / $1,976.48
| Facility | | $1,976.48 | $1,976.48 | $1,976.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.24 / $1,976.48 / $2,100.44
| Professional | | $1,042.24 | $1,976.48 | $2,100.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $978.58 / $1,223.23 / $1,976.48
| Facility | | $978.58 | $1,223.23 | $1,976.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.63 / $1,976.48 / $2,589.30
| Professional | | $1,196.63 | $1,976.48 | $2,589.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.98 / $2,060.17 / $2,350.25
| Professional | | $1,699.98 | $2,060.17 | $2,350.25 |