- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.35 / $1,628.91 / $1,733.52
| Professional | | $1,509.35 | $1,628.91 | $1,733.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,705.81 / $1,705.81 / $1,705.81
| Facility | | $1,705.81 | $1,705.81 | $1,705.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,705.81 / $1,705.81
| Professional | | $1,494.41 | $1,705.81 | $1,705.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,034.21 / $1,494.41 / $1,705.81
| Facility | | $1,034.21 | $1,494.41 | $1,705.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.22 / $1,621.29 / $2,114.73
| Professional | | $1,621.22 | $1,621.29 | $2,114.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.41 / $1,494.41 / $1,494.41
| Professional | | $1,494.41 | $1,494.41 | $1,494.41 |