- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.51 / $1,409.51 / $2,468.42
| Professional | | $1,409.51 | $1,409.51 | $2,468.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,752.94 / $2,752.94 / $2,752.94
| Facility | | $2,752.94 | $2,752.94 | $2,752.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,752.94 / $2,752.94 / $2,752.94
| Professional | | $2,752.94 | $2,752.94 | $2,752.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $3,033.16
| Facility | | $2,373.71 | $2,373.71 | $3,033.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,017.65 / $2,373.71
| Professional | | $2,017.65 | $2,017.65 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.36 / $1,776.73 / $2,053.41
| Professional | | $1,204.36 | $1,776.73 | $2,053.41 |