- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.81 / $1,127.81 / $1,763.48
| Professional | | $1,127.81 | $1,127.81 | $1,763.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,966.74 / $1,966.74 / $1,966.74
| Facility | | $1,966.74 | $1,966.74 | $1,966.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.74 / $1,966.74 / $1,966.74
| Professional | | $1,966.74 | $1,966.74 | $1,966.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $2,215.35
| Facility | | $1,544.16 | $1,544.16 | $2,215.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,127.24 / $1,544.16
| Professional | | $1,127.24 | $1,127.24 | $1,544.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.10 / $1,004.74 / $1,115.45
| Professional | | $908.10 | $1,004.74 | $1,115.45 |