- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.74 / $1,324.74 / $2,319.96
| Professional | | $1,324.74 | $1,324.74 | $2,319.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,587.37 / $2,587.37 / $2,587.37
| Facility | | $2,587.37 | $2,587.37 | $2,587.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,587.37 / $2,587.37 / $2,587.37
| Professional | | $2,587.37 | $2,587.37 | $2,587.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $2,868.65
| Facility | | $1,482.94 | $1,482.94 | $2,868.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,260.50 / $1,482.94
| Professional | | $1,260.50 | $1,260.50 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.10 / $1,578.65 / $1,824.48
| Professional | | $1,070.10 | $1,578.65 | $1,824.48 |