- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.67 / $1,058.67 / $1,058.67
| Professional | | $1,058.67 | $1,058.67 | $1,058.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,310.37 / $2,310.37 / $2,310.37
| Facility | | $2,310.37 | $2,310.37 | $2,310.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.51 / $2,310.37 / $2,310.37
| Professional | | $1,436.51 | $2,310.37 | $2,310.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,019.47 / $1,418.23 / $2,310.37
| Facility | | $1,019.47 | $1,418.23 | $2,310.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.64 / $1,716.27 / $2,310.37
| Professional | | $1,115.64 | $1,716.27 | $2,310.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.99 / $1,877.97 / $2,045.89
| Professional | | $1,686.99 | $1,877.97 | $2,045.89 |