- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,367.13 / $2,367.13 / $4,145.47
| Professional | | $2,367.13 | $2,367.13 | $4,145.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,623.30 / $4,623.30 / $4,623.30
| Facility | | $4,623.30 | $4,623.30 | $4,623.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,623.30 / $4,623.30 / $4,623.30
| Professional | | $4,623.30 | $4,623.30 | $4,623.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,802.84 / $2,802.84 / $5,093.68
| Facility | | $2,802.84 | $2,802.84 | $5,093.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,382.41 / $2,382.41 / $2,802.84
| Professional | | $2,382.41 | $2,382.41 | $2,802.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.56 / $2,237.80 / $3,448.38
| Professional | | $2,022.56 | $2,237.80 | $3,448.38 |