- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,697.57 / $1,697.57 / $2,972.90
| Professional | | $1,697.57 | $1,697.57 | $2,972.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,315.56 / $3,315.56 / $3,315.56
| Facility | | $3,315.56 | $3,315.56 | $3,315.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,315.56 / $3,315.56 / $3,315.56
| Professional | | $3,315.56 | $3,315.56 | $3,315.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $3,915.68
| Facility | | $2,479.82 | $2,479.82 | $3,915.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $1,810.27 / $2,479.82
| Professional | | $1,810.27 | $1,810.27 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.99 / $1,550.09 / $2,388.64
| Professional | | $1,400.99 | $1,550.09 | $2,388.64 |