- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.88 / $1,284.88 / $2,009.08
| Professional | | $1,284.88 | $1,284.88 | $2,009.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,240.65 / $2,240.65 / $2,240.65
| Facility | | $2,240.65 | $2,240.65 | $2,240.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.65 / $2,240.65 / $2,240.65
| Professional | | $2,240.65 | $2,240.65 | $2,240.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.07 / $1,306.07 / $2,299.21
| Facility | | $1,306.07 | $1,306.07 | $2,299.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.43 / $953.43 / $1,306.07
| Professional | | $953.43 | $953.43 | $1,306.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.47 / $1,042.77 / $1,157.68
| Professional | | $942.47 | $1,042.77 | $1,157.68 |