- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.36 / $1,732.36 / $3,033.83
| Professional | | $1,732.36 | $1,732.36 | $3,033.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,383.51 / $3,383.51 / $3,383.51
| Facility | | $3,383.51 | $3,383.51 | $3,383.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,383.51 / $3,383.51 / $3,383.51
| Professional | | $3,383.51 | $3,383.51 | $3,383.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.18 / $1,769.18 / $3,442.37
| Facility | | $1,769.18 | $1,769.18 | $3,442.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.50 / $1,291.50 / $1,769.17
| Professional | | $1,291.50 | $1,291.50 | $1,769.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.65 / $1,412.51 / $2,176.64
| Professional | | $1,276.65 | $1,412.51 | $2,176.64 |