- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.70 / $1,456.90 / $2,902.23
| Professional | | $1,104.70 | $1,456.90 | $2,902.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.33 / $2,225.09 / $3,768.75
| Professional | | $1,891.33 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,964.88 / $1,964.88 / $2,213.12
| Professional | | $1,964.88 | $1,964.88 | $2,213.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.91 / $1,309.92 / $1,989.65
| Professional | | $995.91 | $1,309.92 | $1,989.65 |