- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,168.69
| Professional | | $3,388.44 | $3,388.44 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $5,248.07
| Facility | | $3,981.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $11,220.18 / $11,220.18
| Professional | | $2,089.30 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,760.83 / $6,760.83
| Facility | | $3,388.44 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,819.70
| Professional | | $1,412.54 | $1,412.54 | $1,819.70 |