- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.33 / $2,162.33 / $3,786.83
| Professional | | $2,162.33 | $2,162.33 | $3,786.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,223.30 / $4,223.30 / $4,223.30
| Facility | | $4,223.30 | $4,223.30 | $4,223.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,223.30 / $4,223.30 / $4,223.30
| Professional | | $4,223.30 | $4,223.30 | $4,223.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,741.63 / $2,741.63 / $4,635.42
| Facility | | $2,741.63 | $2,741.63 | $4,635.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.39 / $2,001.39 / $2,741.63
| Professional | | $2,001.39 | $2,001.39 | $2,741.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.12 / $2,803.10 / $3,239.62
| Professional | | $1,900.12 | $2,803.10 | $3,239.62 |