- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,319.04 / $1,319.04 / $2,062.48
| Professional | | $1,319.04 | $1,319.04 | $2,062.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,300.21 / $2,300.21 / $2,300.21
| Facility | | $2,300.21 | $2,300.21 | $2,300.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,300.21 / $2,300.21 / $2,300.21
| Professional | | $2,300.21 | $2,300.21 | $2,300.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.55 / $1,300.55 / $2,550.26
| Facility | | $1,300.55 | $1,300.55 | $2,550.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.40 / $949.40 / $2,066.16
| Professional | | $949.40 | $949.40 | $2,066.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.49 / $1,038.36 / $1,152.79
| Professional | | $938.49 | $1,038.36 | $1,152.79 |