- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.17 / $1,482.17 / $2,595.67
| Professional | | $1,482.17 | $1,482.17 | $2,595.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,894.86 / $2,894.86 / $2,894.86
| Facility | | $2,894.86 | $2,894.86 | $2,894.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,894.86 / $2,894.86 / $2,894.86
| Professional | | $2,894.86 | $2,894.86 | $2,894.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $3,246.66
| Facility | | $2,253.75 | $2,253.75 | $3,246.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $1,915.69 / $2,253.75
| Professional | | $1,915.69 | $1,915.69 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.85 / $1,472.48 / $2,269.04
| Professional | | $1,330.85 | $1,472.48 | $2,269.04 |