- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.81 / $1,980.81 / $1,980.81
| Professional | | $1,980.81 | $1,980.81 | $1,980.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,477.04 / $2,477.04 / $2,477.04
| Facility | | $2,477.04 | $2,477.04 | $2,477.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.04 / $2,477.04 / $2,477.04
| Professional | | $2,477.04 | $2,477.04 | $2,477.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,477.04 / $2,477.04 / $2,477.04
| Facility | | $2,477.04 | $2,477.04 | $2,477.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.04 / $2,477.04 / $4,083.70
| Professional | | $2,477.04 | $2,477.04 | $4,083.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,815.20 / $3,312.01 / $5,105.97
| Professional | | $2,815.20 | $3,312.01 | $5,105.97 |