- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,223.29 / $2,977.62 / $2,977.62
| Professional | | $2,223.29 | $2,977.62 | $2,977.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.12 / $3,248.38 / $3,248.38
| Professional | | $2,761.12 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Professional | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.84 / $3,546.56 / $4,610.87
| Professional | | $1,730.84 | $3,546.56 | $4,610.87 |