- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.96 / $2,261.73 / $8,471.43
| Professional | | $1,730.96 | $2,261.73 | $8,471.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,566.96 / $2,566.96 / $2,566.96
| Facility | | $2,566.96 | $2,566.96 | $2,566.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.06 / $2,566.96 / $2,737.15
| Professional | | $1,350.06 | $2,566.96 | $2,737.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.03 / $1,746.29 / $2,566.96
| Facility | | $1,270.03 | $1,746.29 | $2,566.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.68 / $2,566.96 / $3,368.40
| Professional | | $1,556.68 | $2,566.96 | $3,368.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.32 / $2,631.43 / $3,007.35
| Professional | | $1,663.32 | $2,631.43 | $3,007.35 |