- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.78 / $1,394.78 / $2,442.62
| Professional | | $1,394.78 | $1,394.78 | $2,442.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,724.16 / $2,724.16 / $2,724.16
| Facility | | $2,724.16 | $2,724.16 | $2,724.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,724.16 / $2,724.16 / $2,724.16
| Professional | | $2,724.16 | $2,724.16 | $2,724.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $3,477.42
| Facility | | $1,743.07 | $1,743.07 | $3,477.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $2,769.52
| Professional | | $1,272.44 | $1,272.44 | $2,769.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.82 / $1,391.68 / $2,144.53
| Professional | | $1,257.82 | $1,391.68 | $2,144.53 |