- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,025.09 / $2,025.09 / $3,546.48
| Professional | | $2,025.09 | $2,025.09 | $3,546.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,955.25 / $3,955.25 / $3,955.25
| Facility | | $3,955.25 | $3,955.25 | $3,955.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,955.25 / $3,955.25 / $3,955.25
| Professional | | $3,955.25 | $3,955.25 | $3,955.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $4,024.27
| Facility | | $2,637.76 | $2,637.76 | $4,024.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $1,925.56 / $2,637.76
| Professional | | $1,925.56 | $1,925.56 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.78 / $1,653.86 / $2,548.54
| Professional | | $1,494.78 | $1,653.86 | $2,548.54 |