- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.23 / $1,447.18 / $1,447.18
| Professional | | $1,350.23 | $1,447.18 | $1,447.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,097.42 / $2,097.42 / $2,097.42
| Facility | | $2,097.42 | $2,097.42 | $2,097.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.81 / $1,887.68 / $2,097.42
| Professional | | $1,782.81 | $1,887.68 | $2,097.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.48 / $798.48 / $2,097.42
| Facility | | $798.48 | $798.48 | $2,097.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.81 / $2,097.42 / $2,783.87
| Professional | | $1,782.81 | $2,097.42 | $2,783.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,919.13 / $2,182.54 / $2,408.32
| Professional | | $1,919.13 | $2,182.54 | $2,408.32 |