- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.31 / $1,409.31 / $2,203.66
| Professional | | $1,409.31 | $1,409.31 | $2,203.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,457.65 / $2,457.65 / $2,457.65
| Facility | | $2,457.65 | $2,457.65 | $2,457.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,457.65 / $2,457.65 / $2,457.65
| Professional | | $2,457.65 | $2,457.65 | $2,457.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.41 / $1,179.41 / $2,076.23
| Facility | | $1,179.41 | $1,179.41 | $2,076.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.97 / $860.97 / $1,179.40
| Professional | | $860.97 | $860.97 | $1,179.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.07 / $941.64 / $1,045.41
| Professional | | $851.07 | $941.64 | $1,045.41 |