- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.81 / $1,050.81 / $1,643.08
| Professional | | $1,050.81 | $1,050.81 | $1,643.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.46 / $1,832.46 / $1,832.46
| Facility | | $1,832.46 | $1,832.46 | $1,832.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.46 / $1,832.46 / $1,832.46
| Professional | | $1,832.46 | $1,832.46 | $1,832.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $2,064.08
| Facility | | $1,172.51 | $1,172.51 | $2,064.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $855.93 / $1,172.51
| Professional | | $855.93 | $855.93 | $1,172.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.10 / $936.14 / $1,432.54
| Professional | | $846.10 | $936.14 | $1,432.54 |