- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.90 / $1,572.90 / $2,743.50
| Professional | | $1,572.90 | $1,572.90 | $2,743.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,072.10 / $3,072.10 / $3,072.10
| Professional | | $3,072.10 | $3,072.10 | $3,072.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $3,047.80
| Facility | | $1,850.09 | $1,850.09 | $3,047.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $1,850.09
| Professional | | $1,850.09 | $1,850.09 | $1,850.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.14 / $1,831.82 / $2,604.28
| Professional | | $1,555.14 | $1,831.82 | $2,604.28 |