- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.49 / $1,982.49 / $3,471.87
| Professional | | $1,982.49 | $1,982.49 | $3,471.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,872.04 / $3,872.04 / $3,872.04
| Facility | | $3,872.04 | $3,872.04 | $3,872.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,872.04 / $3,872.04 / $3,872.04
| Professional | | $3,872.04 | $3,872.04 | $3,872.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,728.17 / $2,728.17 / $4,656.78
| Facility | | $2,728.17 | $2,728.17 | $4,656.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.56 / $1,991.56 / $3,936.25
| Professional | | $1,991.56 | $1,991.56 | $3,936.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.82 / $2,637.44 / $3,048.16
| Professional | | $1,787.82 | $2,637.44 | $3,048.16 |