- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.45 / $2,141.40 / $10,505.10
| Professional | | $1,693.45 | $2,141.40 | $10,505.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,166.89 / $3,166.89 / $3,166.89
| Facility | | $3,166.89 | $3,166.89 | $3,166.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.25 / $3,166.89 / $3,428.56
| Professional | | $1,717.25 | $3,166.89 | $3,428.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,566.56 / $2,154.02 / $3,166.89
| Facility | | $1,566.56 | $2,154.02 | $3,166.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,922.88 / $3,166.89 / $4,160.80
| Professional | | $1,922.88 | $3,166.89 | $4,160.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.23 / $3,331.99 / $3,807.99
| Professional | | $2,546.23 | $3,331.99 | $3,807.99 |