- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.99 / $1,741.32 / $6,782.96
| Professional | | $1,287.99 | $1,741.32 | $6,782.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.62 / $2,050.62 / $2,050.62
| Facility | | $2,050.62 | $2,050.62 | $2,050.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.47 / $2,050.62 / $2,484.56
| Professional | | $919.47 | $2,050.62 | $2,484.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.38 / $1,394.78 / $2,050.62
| Facility | | $1,014.38 | $1,394.78 | $2,050.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.50 / $2,050.62 / $2,786.70
| Professional | | $1,244.50 | $2,050.62 | $2,786.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.12 / $2,185.44 / $2,719.72
| Professional | | $1,770.12 | $2,185.44 | $2,719.72 |