- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,188.69 / $2,188.69 / $3,832.98
| Professional | | $2,188.69 | $2,188.69 | $3,832.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,274.78 / $4,274.78 / $4,274.78
| Facility | | $4,274.78 | $4,274.78 | $4,274.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,274.78 / $4,274.78 / $4,274.78
| Professional | | $4,274.78 | $4,274.78 | $4,274.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $5,169.77
| Facility | | $3,001.57 | $3,001.57 | $5,169.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $2,191.15 / $3,001.57
| Professional | | $2,191.15 | $2,191.15 | $3,001.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.14 / $1,975.10 / $3,043.56
| Professional | | $1,826.14 | $1,975.10 | $3,043.56 |