- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.69 / $1,856.69 / $3,251.57
| Professional | | $1,856.69 | $1,856.69 | $3,251.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.35 / $3,626.35 / $3,626.35
| Facility | | $3,626.35 | $3,626.35 | $3,626.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,626.35 / $3,626.35 / $3,626.35
| Professional | | $3,626.35 | $3,626.35 | $3,626.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.02 / $2,125.02 / $3,321.18
| Facility | | $2,125.02 | $2,125.02 | $3,321.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $1,551.26 / $2,125.02
| Professional | | $1,551.26 | $1,551.26 | $2,125.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,255.78 / $1,852.57 / $2,141.06
| Professional | | $1,255.78 | $1,852.57 | $2,141.06 |