- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,922.39 / $2,984.34
| Professional | | $1,730.32 | $1,922.39 | $2,984.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,942.53 / $1,942.53 / $1,958.86
| Facility | | $1,942.53 | $1,942.53 | $1,958.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.38 / $1,890.90 / $3,151.50
| Facility | | $1,632.38 | $1,890.90 | $3,151.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.38 / $1,890.90 / $3,151.50
| Facility | | $1,632.38 | $1,890.90 | $3,151.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,643.80 / $1,831.33 / $1,926.21
| Professional | | $1,643.80 | $1,831.33 | $1,926.21 |