- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.89 / $8,123.08 / $8,123.08
| Professional | | $1,657.89 | $8,123.08 | $8,123.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,600.08 / $2,600.08 / $2,600.08
| Facility | | $2,600.08 | $2,600.08 | $2,600.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.88 / $2,600.08 / $2,811.06
| Professional | | $1,600.88 | $2,600.08 | $2,811.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,280.15 / $2,694.90 / $2,912.66
| Facility | | $1,280.15 | $2,694.90 | $2,912.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.53 / $2,342.54 / $3,378.90
| Professional | | $1,561.53 | $2,342.54 | $3,378.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.48 / $2,763.57 / $4,533.41
| Professional | | $2,201.48 | $2,763.57 | $4,533.41 |