- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.21 / $1,253.21 / $2,194.71
| Professional | | $1,253.21 | $1,253.21 | $2,194.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,447.67 / $2,447.67 / $2,447.67
| Facility | | $2,447.67 | $2,447.67 | $2,447.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,447.67 / $2,447.67 / $2,447.67
| Professional | | $2,447.67 | $2,447.67 | $2,447.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.17 / $1,787.17 / $3,366.53
| Facility | | $1,787.17 | $1,787.17 | $3,366.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $1,304.63 / $2,432.32
| Professional | | $1,304.63 | $1,304.63 | $2,432.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.77 / $1,629.79 / $1,883.60
| Professional | | $1,104.77 | $1,629.79 | $1,883.60 |