- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.91 / $2,272.91 / $3,980.47
| Professional | | $2,272.91 | $2,272.91 | $3,980.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,439.27 / $4,439.27 / $4,439.27
| Facility | | $4,439.27 | $4,439.27 | $4,439.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,439.27 / $4,439.27 / $4,439.27
| Professional | | $4,439.27 | $4,439.27 | $4,439.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,550.04 / $2,550.04 / $5,234.93
| Facility | | $2,550.04 | $2,550.04 | $5,234.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,861.53 / $1,861.53 / $2,550.04
| Professional | | $1,861.53 | $1,861.53 | $2,550.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.13 / $2,035.96 / $3,137.34
| Professional | | $1,840.13 | $2,035.96 | $3,137.34 |