- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,618.83 / $2,618.83 / $2,618.83
| Professional | | $2,618.83 | $2,618.83 | $2,618.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.76 / $1,552.76 / $1,552.76
| Facility | | $1,552.76 | $1,552.76 | $1,552.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $1,133.51
| Professional | | $1,133.51 | $1,133.51 | $1,133.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.34 / $800.34 / $800.34
| Facility | | $800.34 | $800.34 | $800.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,841.12 / $3,028.62 / $4,485.97
| Professional | | $2,841.12 | $3,028.62 | $4,485.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $800.34 / $800.34 / $1,552.76
| Facility | | $800.34 | $800.34 | $1,552.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $2,364.44 / $3,504.67
| Professional | | $1,133.51 | $2,364.44 | $3,504.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.01 / $1,492.01 / $2,859.68
| Professional | | $1,492.01 | $1,492.01 | $2,859.68 |