- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.30 / $1,214.30 / $2,126.57
| Professional | | $1,214.30 | $1,214.30 | $2,126.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,371.67 / $2,371.67 / $2,371.67
| Facility | | $2,371.67 | $2,371.67 | $2,371.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,371.67 / $2,371.67 / $2,371.67
| Professional | | $2,371.67 | $2,371.67 | $2,371.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,964.43 / $1,964.43 / $3,109.12
| Facility | | $1,964.43 | $1,964.43 | $3,109.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.03 / $1,434.03 / $1,964.43
| Professional | | $1,434.03 | $1,434.03 | $1,964.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.58 / $1,536.58 / $1,775.86
| Professional | | $1,041.58 | $1,536.58 | $1,775.86 |