- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.86 / $1,453.43 / $5,423.37
| Professional | | $1,106.86 | $1,453.43 | $5,423.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.06 / $1,652.06 / $1,652.06
| Facility | | $1,652.06 | $1,652.06 | $1,652.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.20 / $1,428.81 / $1,652.06
| Professional | | $854.20 | $1,428.81 | $1,652.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $817.81 / $1,124.49 / $1,652.06
| Facility | | $817.81 | $1,124.49 | $1,652.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.67 / $1,557.85 / $2,158.80
| Professional | | $997.67 | $1,557.85 | $2,158.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.59 / $1,678.32 / $1,918.08
| Professional | | $1,408.59 | $1,678.32 | $1,918.08 |