- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.85 / $1,386.85 / $2,168.52
| Professional | | $1,386.85 | $1,386.85 | $2,168.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,418.46 / $2,418.46 / $2,418.46
| Facility | | $2,418.46 | $2,418.46 | $2,418.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,418.46 / $2,418.46 / $2,418.46
| Professional | | $2,418.46 | $2,418.46 | $2,418.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,399.15 / $1,399.15 / $2,375.77
| Facility | | $1,399.15 | $1,399.15 | $2,375.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.38 / $1,021.38 / $1,399.15
| Professional | | $1,021.38 | $1,021.38 | $1,399.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.16 / $966.08 / $1,455.27
| Professional | | $873.16 | $966.08 | $1,455.27 |