- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.80 / $1,642.80 / $3,147.90
| Professional | | $1,642.80 | $1,642.80 | $3,147.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,189.90 / $3,189.90 / $3,189.90
| Professional | | $3,189.90 | $3,189.90 | $3,189.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Professional | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.25 / $1,216.64 / $1,982.00
| Professional | | $1,115.25 | $1,216.64 | $1,982.00 |