- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,847.91 / $7,230.56 / $7,230.56
| Professional | | $1,847.91 | $7,230.56 | $7,230.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,223.08 / $2,223.08 / $2,223.08
| Facility | | $2,223.08 | $2,223.08 | $2,223.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.54 / $2,223.08 / $2,351.86
| Professional | | $1,425.54 | $2,223.08 | $2,351.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,097.02 / $2,399.15 / $2,465.48
| Facility | | $1,097.02 | $2,399.15 | $2,465.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.02 / $2,038.75 / $2,940.70
| Professional | | $1,359.02 | $2,038.75 | $2,940.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.60 / $2,407.21 / $3,888.70
| Professional | | $1,917.60 | $2,407.21 | $3,888.70 |