- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.03 / $1,609.03 / $2,817.84
| Professional | | $1,609.03 | $1,609.03 | $2,817.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,142.63 / $3,142.63 / $3,142.63
| Facility | | $3,142.63 | $3,142.63 | $3,142.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,142.63 / $3,142.63 / $3,142.63
| Professional | | $3,142.63 | $3,142.63 | $3,142.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.76 / $1,552.76 / $3,644.62
| Facility | | $1,552.76 | $1,552.76 | $3,644.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.51 / $1,133.51 / $2,466.94
| Professional | | $1,133.51 | $1,133.51 | $2,466.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.48 / $1,239.72 / $1,910.37
| Professional | | $1,120.48 | $1,239.72 | $1,910.37 |