- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,453.59 / $2,453.59 / $2,831.07
| Professional | | $2,453.59 | $2,453.59 | $2,831.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $3,695.49
| Facility | | $2,728.17 | $2,728.17 | $3,695.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $2,469.56
| Professional | | $1,991.56 | $1,991.56 | $2,469.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $3,695.49
| Facility | | $2,728.17 | $2,728.17 | $3,695.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $2,469.56
| Professional | | $1,991.56 | $1,991.56 | $2,469.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.26 / $2,980.36 / $5,812.57
| Professional | | $1,672.26 | $2,980.36 | $5,812.57 |