- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.55 / $2,228.48 / $8,385.77
| Professional | | $1,709.55 | $2,228.48 | $8,385.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,529.62 / $2,529.62 / $2,529.62
| Facility | | $2,529.62 | $2,529.62 | $2,529.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.22 / $2,529.62 / $2,571.28
| Professional | | $1,340.22 | $2,529.62 | $2,571.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,251.34 / $1,720.61 / $2,529.62
| Facility | | $1,251.34 | $1,720.61 | $2,529.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.33 / $2,529.62 / $3,322.20
| Professional | | $1,535.33 | $2,529.62 | $3,322.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,377.62 / $2,610.71 / $3,076.92
| Professional | | $2,377.62 | $2,610.71 | $3,076.92 |