- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.44 / $1,573.44 / $2,755.51
| Professional | | $1,573.44 | $1,573.44 | $2,755.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,073.12 / $3,073.12 / $3,073.12
| Facility | | $3,073.12 | $3,073.12 | $3,073.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,073.12 / $3,073.12 / $3,073.12
| Professional | | $3,073.12 | $3,073.12 | $3,073.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $1,784.15 / $3,746.13
| Facility | | $1,784.15 | $1,784.15 | $3,746.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,302.43 / $1,784.15
| Professional | | $1,302.43 | $1,302.43 | $1,784.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.46 / $1,899.30 / $2,195.07
| Professional | | $1,287.46 | $1,899.30 | $2,195.07 |