- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.03 / $2,309.07 / $8,637.31
| Professional | | $1,733.03 | $2,309.07 | $8,637.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,590.09 / $2,590.09 / $2,590.09
| Facility | | $2,590.09 | $2,590.09 | $2,590.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.45 / $2,590.09 / $2,821.54
| Professional | | $1,370.45 | $2,590.09 | $2,821.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.06 / $1,749.09 / $2,590.09
| Facility | | $1,272.06 | $1,749.09 | $2,590.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.83 / $2,590.09 / $3,405.50
| Professional | | $1,573.83 | $2,590.09 | $3,405.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.10 / $2,696.10 / $3,027.20
| Professional | | $2,223.10 | $2,696.10 | $3,027.20 |