- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.68 / $1,700.50 / $1,750.66
| Professional | | $1,289.68 | $1,700.50 | $1,750.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,173.29 / $5,636.58 / $6,673.06
| Facility | | $4,173.29 | $5,636.58 | $6,673.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.21 / $1,551.21 / $2,594.28
| Professional | | $1,551.21 | $1,551.21 | $2,594.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,707.33 / $1,769.18 / $1,769.18
| Facility | | $1,707.33 | $1,769.18 | $1,769.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.50 / $1,769.17 / $1,769.18
| Professional | | $1,291.50 | $1,769.17 | $1,769.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.13 / $1,881.47 / $2,454.29
| Professional | | $1,386.13 | $1,881.47 | $2,454.29 |