- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.82 / $1,226.82 / $2,148.48
| Professional | | $1,226.82 | $1,226.82 | $2,148.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,396.13 / $2,396.13 / $2,396.13
| Facility | | $2,396.13 | $2,396.13 | $2,396.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.13 / $2,396.13 / $2,396.13
| Professional | | $2,396.13 | $2,396.13 | $2,396.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $3,007.51
| Facility | | $1,424.68 | $1,424.68 | $3,007.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $2,263.55
| Professional | | $1,040.02 | $1,040.02 | $2,263.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.06 / $1,516.62 / $1,752.80
| Professional | | $1,028.06 | $1,516.62 | $1,752.80 |