- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,985.01 / $1,985.01 / $3,476.27
| Professional | | $1,985.01 | $1,985.01 | $3,476.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,876.96 / $3,876.96 / $3,876.96
| Facility | | $3,876.96 | $3,876.96 | $3,876.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,876.96 / $3,876.96 / $3,876.96
| Professional | | $3,876.96 | $3,876.96 | $3,876.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $4,298.38
| Facility | | $2,540.30 | $2,540.30 | $4,298.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $1,854.42 / $2,540.30
| Professional | | $1,854.42 | $1,854.42 | $2,540.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.79 / $1,750.12 / $2,696.88
| Professional | | $1,581.79 | $1,750.12 | $2,696.88 |