- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,718.93 / $1,718.93 / $3,010.30
| Professional | | $1,718.93 | $1,718.93 | $3,010.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,357.28 / $3,357.28 / $3,357.28
| Facility | | $3,357.28 | $3,357.28 | $3,357.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,357.28 / $3,357.28 / $3,357.28
| Professional | | $3,357.28 | $3,357.28 | $3,357.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $3,343.78
| Facility | | $2,050.41 | $2,050.41 | $3,343.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $2,835.43
| Professional | | $1,496.80 | $1,496.80 | $2,835.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.77 / $1,899.75 / $2,195.59
| Professional | | $1,287.77 | $1,899.75 | $2,195.59 |