- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.25 / $1,248.25 / $1,951.80
| Professional | | $1,248.25 | $1,248.25 | $1,951.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,176.77 / $2,176.77 / $2,176.77
| Facility | | $2,176.77 | $2,176.77 | $2,176.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,176.77 / $2,176.77 / $2,176.77
| Professional | | $2,176.77 | $2,176.77 | $2,176.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.41 / $1,108.41 / $2,138.87
| Facility | | $1,108.41 | $1,108.41 | $2,138.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.14 / $809.14 / $1,108.41
| Professional | | $809.14 | $809.14 | $1,108.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.74 / $871.57 / $967.61
| Professional | | $787.74 | $871.57 | $967.61 |