- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.17 / $2,298.17 / $4,024.73
| Professional | | $2,298.17 | $2,298.17 | $4,024.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,488.63 / $4,488.63 / $4,488.63
| Facility | | $4,488.63 | $4,488.63 | $4,488.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,488.63 / $4,488.63 / $4,488.63
| Professional | | $4,488.63 | $4,488.63 | $4,488.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $4,976.55
| Facility | | $2,941.06 | $2,941.06 | $4,976.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $4,032.11
| Professional | | $2,146.96 | $2,146.96 | $4,032.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.34 / $2,701.65 / $3,122.37
| Professional | | $1,831.34 | $2,701.65 | $3,122.37 |