- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,389.03 / $2,389.03 / $4,183.83
| Professional | | $2,389.03 | $2,389.03 | $4,183.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,666.06 / $4,666.06 / $4,666.06
| Facility | | $4,666.06 | $4,666.06 | $4,666.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,666.06 / $4,666.06 / $4,666.06
| Professional | | $4,666.06 | $4,666.06 | $4,666.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.78 / $3,813.78 / $5,538.71
| Facility | | $3,813.78 | $3,813.78 | $5,538.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.06 / $2,784.06 / $3,813.78
| Professional | | $2,784.06 | $2,784.06 | $3,813.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,016.28 / $2,974.48 / $3,437.68
| Professional | | $2,016.28 | $2,974.48 | $3,437.68 |