- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.54 / $1,343.84 / $7,101.58
| Professional | | $1,214.54 | $1,343.84 | $7,101.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,169.44 / $2,169.44 / $2,169.44
| Facility | | $2,169.44 | $2,169.44 | $2,169.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.28 / $2,169.44 / $2,169.44
| Professional | | $1,567.28 | $2,169.44 | $2,169.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,169.44 / $2,567.50 / $2,669.15
| Facility | | $2,169.44 | $2,567.50 | $2,669.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.17 / $1,871.70 / $2,858.80
| Professional | | $1,321.17 | $1,871.70 | $2,858.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.50 / $2,372.39 / $3,767.53
| Professional | | $2,014.50 | $2,372.39 | $3,767.53 |