- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.25 / $1,389.25 / $2,432.94
| Professional | | $1,389.25 | $1,389.25 | $2,432.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,713.38 / $2,713.38 / $2,713.38
| Facility | | $2,713.38 | $2,713.38 | $2,713.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.38 / $2,713.38 / $2,713.38
| Professional | | $2,713.38 | $2,713.38 | $2,713.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,721.98 / $1,721.98 / $3,434.81
| Facility | | $1,721.98 | $1,721.98 | $3,434.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.05 / $1,257.05 / $1,721.98
| Professional | | $1,257.05 | $1,257.05 | $1,721.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.59 / $1,557.81 / $2,118.58
| Professional | | $1,242.59 | $1,557.81 | $2,118.58 |