- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.78 / $1,395.78 / $2,444.38
| Professional | | $1,395.78 | $1,395.78 | $2,444.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,726.12 / $2,726.12 / $2,726.12
| Facility | | $2,726.12 | $2,726.12 | $2,726.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,726.12 / $2,726.12 / $2,726.12
| Professional | | $2,726.12 | $2,726.12 | $2,726.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.24 / $1,786.24 / $3,022.51
| Facility | | $1,786.24 | $1,786.24 | $3,022.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.96 / $1,303.96 / $1,786.24
| Professional | | $1,303.96 | $1,303.96 | $1,786.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.25 / $1,640.82 / $1,896.34
| Professional | | $1,112.25 | $1,640.82 | $1,896.34 |