- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,548.13
| Facility | | $2,951.21 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,079.46 / $7,079.46
| Professional | | $2,818.38 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,041.74 / $2,041.74
| Facility | | $1,023.29 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,230.27 / $1,230.27
| Professional | | $851.14 | $1,230.27 | $1,230.27 |