- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.40 / $1,185.40 / $1,853.53
| Professional | | $1,185.40 | $1,185.40 | $1,853.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,067.17 / $2,067.17 / $2,067.17
| Facility | | $2,067.17 | $2,067.17 | $2,067.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.17 / $2,067.17 / $2,067.17
| Professional | | $2,067.17 | $2,067.17 | $2,067.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,184.20 / $1,184.20 / $2,248.84
| Facility | | $1,184.20 | $1,184.20 | $2,248.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.47 / $864.47 / $1,184.20
| Professional | | $864.47 | $864.47 | $1,184.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.92 / $880.62 / $977.66
| Professional | | $795.92 | $880.62 | $977.66 |