- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.30 / $1,894.98 / $2,093.36
| Professional | | $1,458.30 | $1,894.98 | $2,093.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,098.56 / $2,098.56 / $2,098.56
| Facility | | $2,098.56 | $2,098.56 | $2,098.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,098.56 / $2,098.56 / $2,098.56
| Professional | | $2,098.56 | $2,098.56 | $2,098.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $2,491.32
| Facility | | $1,786.79 | $1,786.79 | $2,491.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $2,273.92
| Professional | | $1,518.77 | $1,786.79 | $2,273.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.40 / $1,249.64 / $2,200.33
| Professional | | $893.40 | $1,249.64 | $2,200.33 |