- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.04 / $2,453.63 / $2,453.63
| Professional | | $1,832.04 | $2,453.63 | $2,453.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.33 / $2,225.09 / $2,291.84
| Professional | | $1,891.33 | $2,225.09 | $2,291.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,291.84
| Professional | | $2,225.09 | $2,225.09 | $2,291.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.68 / $1,657.54 / $2,183.19
| Professional | | $753.68 | $1,657.54 | $2,183.19 |