- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.94 / $7,123.84 / $7,123.84
| Professional | | $1,581.94 | $7,123.84 | $7,123.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,172.08 / $2,172.08 / $2,172.08
| Facility | | $2,172.08 | $2,172.08 | $2,172.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.91 / $2,172.08 / $2,172.08
| Professional | | $1,712.91 | $2,172.08 | $2,172.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,172.08 / $2,843.10 / $2,936.70
| Facility | | $2,172.08 | $2,843.10 | $2,936.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.67 / $1,895.07 / $2,894.50
| Professional | | $1,337.67 | $1,895.07 | $2,894.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.12 / $2,463.60 / $3,805.45
| Professional | | $2,135.12 | $2,463.60 | $3,805.45 |