- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.44 / $1,845.94 / $9,738.54
| Professional | | $1,542.44 | $1,845.94 | $9,738.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,969.19 / $2,969.19 / $2,969.19
| Facility | | $2,969.19 | $2,969.19 | $2,969.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.15 / $2,969.19 / $5,320.11
| Professional | | $1,741.15 | $2,969.19 | $5,320.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,828.17 / $2,415.52 / $3,371.86
| Facility | | $1,828.17 | $2,415.52 | $3,371.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.21 / $3,041.63 / $5,068.43
| Professional | | $1,861.21 | $3,041.63 | $5,068.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.59 / $3,115.51 / $4,121.85
| Professional | | $2,583.59 | $3,115.51 | $4,121.85 |