- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.84 / $3,360.06 / $3,360.06
| Professional | | $2,508.84 | $3,360.06 | $3,360.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.88 / $1,642.21 / $1,691.48
| Professional | | $1,395.88 | $1,642.21 | $1,691.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,642.21
| Facility | | $1,642.21 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $1,691.48
| Professional | | $1,642.21 | $1,642.21 | $1,691.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.28 / $4,009.68 / $5,203.09
| Professional | | $1,959.28 | $4,009.68 | $5,203.09 |