- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.54 / $1,414.26 / $5,464.90
| Professional | | $1,110.54 | $1,414.26 | $5,464.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,754.07 / $1,754.07 / $1,754.07
| Facility | | $1,754.07 | $1,754.07 | $1,754.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.36 / $1,754.07 / $1,874.04
| Professional | | $610.36 | $1,754.07 | $1,874.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $864.48 / $1,080.59 / $1,568.60
| Facility | | $864.48 | $1,080.59 | $1,568.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.62 / $1,750.24 / $2,272.19
| Professional | | $986.62 | $1,750.24 | $2,272.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.20 / $1,722.60 / $1,985.06
| Professional | | $1,177.20 | $1,722.60 | $1,985.06 |