- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.63 / $2,235.63 / $3,915.19
| Professional | | $2,235.63 | $2,235.63 | $3,915.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,366.46 / $4,366.46 / $4,366.46
| Facility | | $4,366.46 | $4,366.46 | $4,366.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,366.46 / $4,366.46 / $4,366.46
| Professional | | $4,366.46 | $4,366.46 | $4,366.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $4,841.16
| Facility | | $3,060.59 | $3,060.59 | $4,841.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $3,922.27
| Professional | | $2,234.23 | $2,234.23 | $3,922.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,781.51 / $1,971.11 / $3,037.41
| Professional | | $1,781.51 | $1,971.11 | $3,037.41 |