- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.92 / $1,829.92 / $3,204.68
| Professional | | $1,829.92 | $1,829.92 | $3,204.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,574.06 / $3,574.06 / $3,574.06
| Facility | | $3,574.06 | $3,574.06 | $3,574.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,574.06 / $3,574.06 / $3,574.06
| Professional | | $3,574.06 | $3,574.06 | $3,574.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,694.60 / $2,694.60 / $4,312.47
| Facility | | $2,694.60 | $2,694.60 | $4,312.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,967.06 / $1,967.06 / $3,250.52
| Professional | | $1,967.06 | $1,967.06 | $3,250.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.42 / $1,633.54 / $2,517.23
| Professional | | $1,476.42 | $1,633.54 | $2,517.23 |