- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.30 / $1,595.30 / $1,686.46
| Professional | | $1,595.30 | $1,595.30 | $1,686.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,415.79 / $2,684.21 / $2,803.17
| Facility | | $2,415.79 | $2,684.21 | $2,803.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.68 / $3,019.68 / $3,019.68
| Professional | | $3,019.68 | $3,019.68 | $3,019.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,737.96 / $6,737.96 / $6,737.96
| Facility | | $6,737.96 | $6,737.96 | $6,737.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $1,367.40 / $3,646.40
| Professional | | $957.18 | $1,367.40 | $3,646.40 |