- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.43 / $1,732.43 / $3,033.95
| Professional | | $1,732.43 | $1,732.43 | $3,033.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,383.65 / $3,383.65 / $3,383.65
| Facility | | $3,383.65 | $3,383.65 | $3,383.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,383.65 / $3,383.65 / $3,383.65
| Professional | | $3,383.65 | $3,383.65 | $3,383.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,217.07 / $2,217.07 / $3,751.50
| Facility | | $2,217.07 | $2,217.07 | $3,751.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.46 / $1,618.46 / $2,217.07
| Professional | | $1,618.46 | $1,618.46 | $2,217.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,153.33 / $2,018.42 / $2,018.42
| Facility | | $1,153.33 | $2,018.42 | $2,018.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.52 / $1,527.44 / $2,353.73
| Professional | | $1,380.52 | $1,527.44 | $2,353.73 |