- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.45 / $1,842.45 / $3,226.62
| Professional | | $1,842.45 | $1,842.45 | $3,226.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,598.53 / $3,598.53 / $3,598.53
| Facility | | $3,598.53 | $3,598.53 | $3,598.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,598.53 / $3,598.53 / $3,598.53
| Professional | | $3,598.53 | $3,598.53 | $3,598.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.62 / $2,289.62 / $3,708.89
| Facility | | $2,289.62 | $2,289.62 | $3,708.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.42 / $1,671.42 / $2,864.39
| Professional | | $1,671.42 | $1,671.42 | $2,864.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.99 / $1,439.45 / $3,539.42
| Professional | | $1,300.99 | $1,439.45 | $3,539.42 |