- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.63 / $1,808.63 / $3,167.39
| Professional | | $1,808.63 | $1,808.63 | $3,167.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,532.47 / $3,532.47 / $3,532.47
| Facility | | $3,532.47 | $3,532.47 | $3,532.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,532.47 / $3,532.47 / $3,532.47
| Professional | | $3,532.47 | $3,532.47 | $3,532.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $4,025.89
| Facility | | $2,482.86 | $2,482.86 | $4,025.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $1,812.49 / $2,482.86
| Professional | | $1,812.49 | $1,812.49 | $2,482.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,247.08 / $2,182.50 / $2,182.50
| Facility | | $1,247.08 | $2,182.50 | $2,182.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.75 / $1,651.61 / $2,545.08
| Professional | | $1,492.75 | $1,651.61 | $2,545.08 |