- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.30 / $1,406.30 / $2,462.81
| Professional | | $1,406.30 | $1,406.30 | $2,462.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,746.67 / $2,746.67 / $2,746.67
| Facility | | $2,746.67 | $2,746.67 | $2,746.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.67 / $2,746.67 / $2,746.67
| Professional | | $2,746.67 | $2,746.67 | $2,746.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.28 / $1,486.28 / $2,616.44
| Facility | | $1,486.28 | $1,486.28 | $2,616.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,084.98 / $1,486.28
| Professional | | $1,084.98 | $1,084.98 | $1,486.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.51 / $1,186.65 / $1,828.59
| Professional | | $1,072.51 | $1,186.65 | $1,828.59 |