- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.31 / $1,309.67 / $2,047.84
| Professional | | $1,284.31 | $1,309.67 | $2,047.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.88 / $2,283.88 / $2,283.88
| Facility | | $2,283.88 | $2,283.88 | $2,283.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.88 / $2,283.88 / $2,283.88
| Professional | | $2,283.88 | $2,283.88 | $2,283.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,277.46 / $2,228.89
| Facility | | $1,277.46 | $1,277.46 | $2,228.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.55 / $932.55 / $1,277.46
| Professional | | $932.55 | $932.55 | $1,277.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.55 / $938.86 / $1,042.31
| Professional | | $848.55 | $938.86 | $1,042.31 |