- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.78 / $1,582.96 / $1,684.61
| Professional | | $1,466.78 | $1,582.96 | $1,684.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,877.77 / $1,877.77 / $1,877.77
| Facility | | $1,877.77 | $1,877.77 | $1,877.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,877.77 / $1,877.77
| Professional | | $1,452.25 | $1,877.77 | $1,877.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,495.82 / $1,877.77
| Facility | | $1,452.25 | $1,495.82 | $1,877.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.05 / $1,575.56 / $1,947.49
| Professional | | $1,115.05 | $1,575.56 | $1,947.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |