- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.83 / $5,192.60 / $5,192.60
| Professional | | $1,121.83 | $5,192.60 | $5,192.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,603.16 / $1,603.16 / $1,603.16
| Facility | | $1,603.16 | $1,603.16 | $1,603.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.08 / $1,603.16 / $1,662.77
| Professional | | $1,091.08 | $1,603.16 | $1,662.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $791.40 / $1,701.05 / $1,859.55
| Facility | | $791.40 | $1,701.05 | $1,859.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.26 / $1,467.55 / $2,116.80
| Professional | | $978.26 | $1,467.55 | $2,116.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.67 / $1,674.87 / $2,824.03
| Professional | | $1,334.67 | $1,674.87 | $2,824.03 |