- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.67 / $2,410.53 / $3,769.19
| Professional | | $2,178.67 | $2,410.53 | $3,769.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,203.63 / $4,203.63 / $4,203.63
| Facility | | $4,203.63 | $4,203.63 | $4,203.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,203.63 / $4,203.63 / $4,203.63
| Professional | | $4,203.63 | $4,203.63 | $4,203.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $3,551.23
| Facility | | $2,017.28 | $2,017.28 | $3,551.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $1,472.61 / $2,017.28
| Professional | | $1,472.61 | $1,472.61 | $2,017.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.70 / $1,610.60 / $1,788.09
| Professional | | $1,455.70 | $1,610.60 | $1,788.09 |