- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.61 / $2,093.36 / $2,346.80
| Professional | | $1,329.61 | $2,093.36 | $2,346.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.13 / $2,014.13 / $2,014.13
| Professional | | $2,014.13 | $2,014.13 | $2,014.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $3,663.75
| Professional | | $1,786.79 | $1,786.79 | $3,663.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.40 / $1,373.60 / $2,121.82
| Professional | | $893.40 | $1,373.60 | $2,121.82 |