- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.75 / $1,138.75 / $1,994.26
| Professional | | $1,138.75 | $1,138.75 | $1,994.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,224.12 / $2,224.12 / $2,224.12
| Facility | | $2,224.12 | $2,224.12 | $2,224.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.12 / $2,224.12 / $2,224.12
| Professional | | $2,224.12 | $2,224.12 | $2,224.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,654.54 / $2,741.66
| Facility | | $1,654.54 | $1,654.54 | $2,741.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.81 / $1,207.81 / $1,654.54
| Professional | | $1,207.81 | $1,207.81 | $1,654.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.93 / $1,514.96 / $1,750.88
| Professional | | $1,026.93 | $1,514.96 | $1,750.88 |