- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.89 / $1,736.89 / $3,041.76
| Professional | | $1,736.89 | $1,736.89 | $3,041.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,392.36 / $3,392.36 / $3,392.36
| Facility | | $3,392.36 | $3,392.36 | $3,392.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,392.36 / $3,392.36 / $3,392.36
| Professional | | $3,392.36 | $3,392.36 | $3,392.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,571.77 / $3,670.96
| Facility | | $2,571.77 | $2,571.77 | $3,670.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $1,877.39 / $2,571.77
| Professional | | $1,877.39 | $1,877.39 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.68 / $1,664.91 / $2,360.82
| Professional | | $1,384.68 | $1,664.91 | $2,360.82 |