- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.27 / $1,542.27 / $2,700.94
| Professional | | $1,542.27 | $1,542.27 | $2,700.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,012.25 / $3,012.25 / $3,012.25
| Facility | | $3,012.25 | $3,012.25 | $3,012.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.25 / $3,012.25 / $3,012.25
| Professional | | $3,012.25 | $3,012.25 | $3,012.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $3,171.21
| Facility | | $1,769.38 | $1,769.38 | $3,171.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,291.65 / $1,769.38
| Professional | | $1,291.65 | $1,291.65 | $1,769.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.55 / $1,613.24 / $1,864.47
| Professional | | $1,093.55 | $1,613.24 | $1,864.47 |