- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.28 / $1,629.28 / $2,853.30
| Professional | | $1,629.28 | $1,629.28 | $2,853.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,182.18 / $3,182.18 / $3,182.18
| Facility | | $3,182.18 | $3,182.18 | $3,182.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,182.18 / $3,182.18 / $3,182.18
| Professional | | $3,182.18 | $3,182.18 | $3,182.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,561.34 / $2,561.34 / $4,177.51
| Facility | | $2,561.34 | $2,561.34 | $4,177.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $1,869.78 / $2,561.34
| Professional | | $1,869.78 | $1,869.78 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.29 / $1,607.95 / $2,477.80
| Professional | | $1,453.29 | $1,607.95 | $2,477.80 |