- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.37 / $2,113.86 / $11,153.10
| Professional | | $1,767.37 | $2,113.86 | $11,153.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,380.37 / $3,380.37 / $3,380.37
| Facility | | $3,380.37 | $3,380.37 | $3,380.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.18 / $3,380.37 / $6,050.44
| Professional | | $1,952.18 | $3,380.37 | $6,050.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,980.06 / $2,812.65 / $3,859.52
| Facility | | $1,980.06 | $2,812.65 | $3,859.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.33 / $3,464.36 / $5,772.86
| Professional | | $2,132.33 | $3,464.36 | $5,772.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.64 / $3,571.84 / $4,543.68
| Professional | | $2,958.64 | $3,571.84 | $4,543.68 |