- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.66 / $2,672.66 / $2,672.66
| Professional | | $2,672.66 | $2,672.66 | $2,672.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.70 / $1,530.70 / $1,530.70
| Facility | | $1,530.70 | $1,530.70 | $1,530.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.41 / $1,117.41 / $1,117.41
| Professional | | $1,117.41 | $1,117.41 | $1,117.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $571.58 / $571.58 / $571.58
| Facility | | $571.58 | $571.58 | $571.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.94 / $2,899.51 / $4,578.18
| Professional | | $2,247.94 | $2,899.51 | $4,578.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $571.58 / $571.58 / $1,530.70
| Facility | | $571.58 | $571.58 | $1,530.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.41 / $1,754.96 / $3,576.71
| Professional | | $1,117.41 | $1,754.96 | $3,576.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.15 / $1,522.67 / $2,918.45
| Professional | | $1,475.15 | $1,522.67 | $2,918.45 |