- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.77 / $1,843.77 / $3,228.92
| Professional | | $1,843.77 | $1,843.77 | $3,228.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,601.10 / $3,601.10 / $3,601.10
| Facility | | $3,601.10 | $3,601.10 | $3,601.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,601.10 / $3,601.10 / $3,601.10
| Professional | | $3,601.10 | $3,601.10 | $3,601.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $3,939.20
| Facility | | $1,902.78 | $1,902.78 | $3,939.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,389.03 / $1,902.78
| Professional | | $1,389.03 | $1,389.03 | $1,902.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.30 / $1,956.60 / $2,261.29
| Professional | | $1,326.30 | $1,956.60 | $2,261.29 |