- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $4,265.80
| Professional | | $1,348.96 | $1,621.81 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,495.41 / $6,456.54
| Facility | | $4,073.80 | $5,495.41 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,819.70 / $2,951.21
| Professional | | $1,348.96 | $1,819.70 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,137.96
| Facility | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,137.96
| Professional | | $1,548.82 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $3,801.89
| Facility | | $1,819.70 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $2,290.87
| Professional | | $1,318.26 | $1,778.28 | $2,290.87 |