- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.90 / $1,318.90 / $1,521.80
| Professional | | $1,318.90 | $1,318.90 | $1,521.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $1,667.14 / $2,434.60
| Professional | | $1,667.14 | $1,667.14 | $2,434.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,283.76 / $2,283.76
| Facility | | $2,283.76 | $2,283.76 | $2,283.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.14 / $2,283.76 / $2,434.60
| Professional | | $1,667.14 | $2,283.76 | $2,434.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.44 / $2,153.44 / $2,247.23
| Professional | | $1,217.44 | $2,153.44 | $2,247.23 |