- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.56 / $1,657.56 / $2,902.83
| Professional | | $1,657.56 | $1,657.56 | $2,902.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,237.42 / $3,237.42 / $3,237.42
| Facility | | $3,237.42 | $3,237.42 | $3,237.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,237.42 / $3,237.42 / $3,237.42
| Professional | | $3,237.42 | $3,237.42 | $3,237.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,711.28 / $1,711.28 / $4,016.71
| Facility | | $1,711.28 | $1,711.28 | $4,016.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.23 / $1,249.23 / $1,711.28
| Professional | | $1,249.23 | $1,249.23 | $1,711.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.86 / $1,366.29 / $2,105.41
| Professional | | $1,234.86 | $1,366.29 | $2,105.41 |