- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.37 / $1,623.99 / $8,570.83
| Professional | | $1,346.37 | $1,623.99 | $8,570.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,612.17 / $2,612.17 / $2,612.17
| Facility | | $2,612.17 | $2,612.17 | $2,612.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.77 / $2,612.17 / $4,661.28
| Professional | | $1,529.77 | $2,612.17 | $4,661.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,611.25 / $2,103.44 / $2,948.08
| Facility | | $1,611.25 | $2,103.44 | $2,948.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.34 / $2,676.59 / $4,460.14
| Professional | | $1,635.34 | $2,676.59 | $4,460.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.10 / $2,753.10 / $3,486.26
| Professional | | $2,270.10 | $2,753.10 | $3,486.26 |