- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.88 / $1,336.88 / $1,336.88
| Professional | | $1,336.88 | $1,336.88 | $1,336.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,240.14 / $4,240.14 / $4,240.14
| Facility | | $4,240.14 | $4,240.14 | $4,240.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,886.00 / $1,886.00 / $2,312.17
| Professional | | $1,886.00 | $1,886.00 | $2,312.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,886.00 / $1,886.00 / $1,886.00
| Facility | | $1,886.00 | $1,886.00 | $1,886.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.32 / $1,886.00 / $2,498.69
| Professional | | $1,430.32 | $1,886.00 | $2,498.69 |