- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.43 / $1,930.43 / $3,380.69
| Professional | | $1,930.43 | $1,930.43 | $3,380.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,770.36 / $3,770.36 / $3,770.36
| Facility | | $3,770.36 | $3,770.36 | $3,770.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,770.36 / $3,770.36 / $3,770.36
| Professional | | $3,770.36 | $3,770.36 | $3,770.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,381.07 / $2,381.07 / $4,171.89
| Facility | | $2,381.07 | $2,381.07 | $4,171.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.18 / $1,738.18 / $2,381.07
| Professional | | $1,738.18 | $1,738.18 | $2,381.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.89 / $1,699.03 / $2,618.15
| Professional | | $1,570.89 | $1,699.03 | $2,618.15 |