- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.16 / $1,425.16 / $2,495.84
| Professional | | $1,425.16 | $1,425.16 | $2,495.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.52 / $2,783.52 / $2,783.52
| Facility | | $2,783.52 | $2,783.52 | $2,783.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,783.52 / $2,783.52 / $2,783.52
| Professional | | $2,783.52 | $2,783.52 | $2,783.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $2,867.04
| Facility | | $1,823.10 | $1,823.10 | $2,867.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,330.86 / $1,823.10
| Professional | | $1,330.86 | $1,330.86 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.84 / $1,551.72 / $1,793.37
| Professional | | $1,051.84 | $1,551.72 | $1,793.37 |