- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.18 / $1,527.18 / $2,674.50
| Professional | | $1,527.18 | $1,527.18 | $2,674.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,982.77 / $2,982.77 / $2,982.77
| Facility | | $2,982.77 | $2,982.77 | $2,982.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,982.77 / $2,982.77 / $2,982.77
| Professional | | $2,982.77 | $2,982.77 | $2,982.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.29 / $1,808.29 / $3,286.25
| Facility | | $1,808.29 | $1,808.29 | $3,286.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $2,873.04
| Professional | | $1,537.05 | $1,537.05 | $2,873.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.88 / $1,490.43 / $2,224.76
| Professional | | $1,304.88 | $1,490.43 | $2,224.76 |