- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.51 / $2,217.51 / $3,883.46
| Professional | | $2,217.51 | $2,217.51 | $3,883.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,331.07 / $4,331.07 / $4,331.07
| Facility | | $4,331.07 | $4,331.07 | $4,331.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,331.07 / $4,331.07 / $4,331.07
| Professional | | $4,331.07 | $4,331.07 | $4,331.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,448.80 / $2,448.80 / $4,801.93
| Facility | | $2,448.80 | $2,448.80 | $4,801.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.62 / $1,787.62 / $2,448.80
| Professional | | $1,787.62 | $1,787.62 | $2,448.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.07 / $2,606.83 / $3,012.78
| Professional | | $1,767.07 | $2,606.83 | $3,012.78 |