- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,526.02 / $1,526.02 / $2,672.47
| Professional | | $1,526.02 | $1,526.02 | $2,672.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,980.50 / $2,980.50 / $2,980.50
| Facility | | $2,980.50 | $2,980.50 | $2,980.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,980.50 / $2,980.50 / $2,980.50
| Professional | | $2,980.50 | $2,980.50 | $2,980.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,952.91 / $1,952.91 / $3,304.54
| Facility | | $1,952.91 | $1,952.91 | $3,304.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.62 / $1,425.62 / $1,952.91
| Professional | | $1,425.62 | $1,425.62 | $1,952.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.04 / $1,345.45 / $2,073.29
| Professional | | $1,216.04 | $1,345.45 | $2,073.29 |