- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,397.21 / $2,397.21 / $2,766.01
| Professional | | $2,397.21 | $2,397.21 | $2,766.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,532.34 / $3,532.34 / $3,610.56
| Facility | | $3,532.34 | $3,532.34 | $3,610.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $3,033.49 / $3,638.31
| Professional | | $2,578.61 | $3,033.49 | $3,638.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,532.34 / $3,532.34 / $3,610.56
| Facility | | $3,532.34 | $3,532.34 | $3,610.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,578.61 / $3,532.34 / $3,638.31
| Professional | | $2,578.61 | $3,532.34 | $3,638.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,050.06 / $3,050.06 / $3,050.06
| Facility | | $3,050.06 | $3,050.06 | $3,050.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.82 / $3,440.27 / $5,678.98
| Professional | | $1,633.82 | $3,440.27 | $5,678.98 |