- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.91 / $1,389.88 / $7,291.17
| Professional | | $1,170.91 | $1,389.88 | $7,291.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,232.55 / $2,232.55 / $2,232.55
| Facility | | $2,232.55 | $2,232.55 | $2,232.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.89 / $2,232.55 / $4,033.63
| Professional | | $1,307.89 | $2,232.55 | $4,033.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.28 / $1,856.25 / $2,544.55
| Facility | | $1,376.28 | $1,856.25 | $2,544.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.02 / $2,278.12 / $3,796.16
| Professional | | $1,398.02 | $2,278.12 | $3,796.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,939.22 / $2,383.81 / $3,548.37
| Professional | | $1,939.22 | $2,383.81 | $3,548.37 |