- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.72 / $1,555.92 / $1,655.84
| Professional | | $1,441.72 | $1,555.92 | $1,655.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,583.37 / $1,583.37 / $1,583.37
| Facility | | $1,583.37 | $1,583.37 | $1,583.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,583.37 / $1,583.37
| Professional | | $1,427.45 | $1,583.37 | $1,583.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,583.37 / $1,824.44
| Facility | | $1,427.45 | $1,583.37 | $1,824.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,504.86 / $1,548.65 / $2,019.98
| Professional | | $1,504.86 | $1,548.65 | $2,019.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Professional | | $1,427.45 | $1,427.45 | $1,427.45 |