- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.06 / $2,065.06 / $3,616.47
| Professional | | $2,065.06 | $2,065.06 | $3,616.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,033.31 / $4,033.31 / $4,033.31
| Facility | | $4,033.31 | $4,033.31 | $4,033.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,033.31 / $4,033.31 / $4,033.31
| Professional | | $4,033.31 | $4,033.31 | $4,033.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $4,543.12
| Facility | | $3,148.57 | $3,148.57 | $4,543.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,298.46 / $3,148.57
| Professional | | $2,298.46 | $2,298.46 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.29 / $2,747.29 / $3,175.12
| Professional | | $1,862.29 | $2,747.29 | $3,175.12 |