- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,494.73 / $2,494.73 / $4,368.93
| Professional | | $2,494.73 | $2,494.73 | $4,368.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,872.52 / $4,872.52 / $4,872.52
| Facility | | $4,872.52 | $4,872.52 | $4,872.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,872.52 / $4,872.52 / $4,872.52
| Professional | | $4,872.52 | $4,872.52 | $4,872.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $5,402.23
| Facility | | $2,801.20 | $2,801.20 | $5,402.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $4,376.97
| Professional | | $2,044.88 | $2,044.88 | $4,376.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.99 / $2,932.74 / $3,389.45
| Professional | | $1,987.99 | $2,932.74 | $3,389.45 |