- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.13 / $2,492.13 / $2,875.54
| Professional | | $2,492.13 | $2,492.13 | $2,875.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $3,753.54
| Facility | | $3,006.81 | $3,006.81 | $3,753.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $3,006.81 / $3,097.01
| Professional | | $2,194.96 | $3,006.81 | $3,097.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,006.81 / $3,006.81 / $3,753.54
| Facility | | $3,006.81 | $3,006.81 | $3,753.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.96 / $3,006.81 / $3,097.01
| Professional | | $2,194.96 | $3,006.81 | $3,097.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $3,134.16 / $5,903.86
| Professional | | $1,698.53 | $3,134.16 | $5,903.86 |