- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.64 / $1,011.64 / $1,771.66
| Professional | | $1,011.64 | $1,011.64 | $1,771.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,975.86 / $1,975.86 / $1,975.86
| Facility | | $1,975.86 | $1,975.86 | $1,975.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.86 / $1,975.86 / $1,975.86
| Professional | | $1,975.86 | $1,975.86 | $1,975.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,375.24 / $2,281.44
| Facility | | $1,375.24 | $1,375.24 | $2,281.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.93 / $1,003.93 / $1,375.24
| Professional | | $1,003.93 | $1,003.93 | $1,375.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.91 / $1,162.33 / $1,343.35
| Professional | | $787.91 | $1,162.33 | $1,343.35 |