- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.61 / $1,920.44 / $3,759.27
| Professional | | $1,390.61 | $1,920.44 | $3,759.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.29 / $2,225.05 / $5,261.25
| Professional | | $1,891.29 | $2,225.05 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.20 / $2,713.20 / $2,713.20
| Professional | | $2,713.20 | $2,713.20 | $2,713.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,833.52 / $2,833.52 / $2,833.52
| Professional | | $2,833.52 | $2,833.52 | $2,833.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.92 / $1,671.89 / $3,135.36
| Professional | | $1,309.92 | $1,671.89 | $3,135.36 |