- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.04 / $1,278.04 / $2,238.17
| Professional | | $1,278.04 | $1,278.04 | $2,238.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,496.16 / $2,496.16 / $2,496.16
| Facility | | $2,496.16 | $2,496.16 | $2,496.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.16 / $2,496.16 / $2,496.16
| Professional | | $2,496.16 | $2,496.16 | $2,496.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $2,536.44
| Facility | | $1,747.16 | $1,747.16 | $2,536.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,275.43 / $1,747.16
| Professional | | $1,275.43 | $1,275.43 | $1,747.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.30 / $1,503.70 / $1,737.86
| Professional | | $1,019.30 | $1,503.70 | $1,737.86 |