- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,645.41 / $1,748.25
| Professional | | $1,645.41 | $1,645.41 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,816.81 / $1,919.65
| Facility | | $1,748.25 | $1,816.81 | $1,919.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.08 / $1,851.08 / $1,851.08
| Professional | | $1,851.08 | $1,851.08 | $1,851.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Facility | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $1,713.97
| Professional | | $1,713.97 | $1,713.97 | $1,713.97 |