- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.78 / $1,657.23 / $6,215.49
| Professional | | $1,269.78 | $1,657.23 | $6,215.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,877.63 / $1,877.63 / $1,877.63
| Facility | | $1,877.63 | $1,877.63 | $1,877.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.37 / $1,877.63 / $2,012.56
| Professional | | $1,005.37 | $1,877.63 | $2,012.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $928.40 / $1,276.55 / $1,877.63
| Facility | | $928.40 | $1,276.55 | $1,877.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.98 / $1,877.63 / $2,468.90
| Professional | | $1,140.98 | $1,877.63 | $2,468.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.90 / $1,962.33 / $2,265.77
| Professional | | $1,622.90 | $1,962.33 | $2,265.77 |