- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.01 / $2,342.01 / $4,101.49
| Professional | | $2,342.01 | $2,342.01 | $4,101.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,574.24 / $4,574.24 / $4,574.24
| Facility | | $4,574.24 | $4,574.24 | $4,574.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,574.24 / $4,574.24 / $4,574.24
| Professional | | $4,574.24 | $4,574.24 | $4,574.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,364.97 / $3,364.97 / $5,432.90
| Facility | | $3,364.97 | $3,364.97 | $5,432.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.42 / $2,456.42 / $3,364.97
| Professional | | $2,456.42 | $2,456.42 | $3,364.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.32 / $2,706.04 / $3,127.45
| Professional | | $1,834.32 | $2,706.04 | $3,127.45 |