- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.25 / $2,059.25 / $2,376.06
| Professional | | $2,059.25 | $2,059.25 | $2,376.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,507.59 / $3,101.56
| Facility | | $2,507.59 | $2,507.59 | $3,101.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,507.59 / $2,582.82
| Professional | | $1,830.54 | $2,507.59 | $2,582.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,507.59 / $2,507.59 / $3,101.56
| Facility | | $2,507.59 | $2,507.59 | $3,101.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.54 / $2,507.59 / $2,582.82
| Professional | | $1,830.54 | $2,507.59 | $2,582.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.49 / $2,499.71 / $4,878.37
| Professional | | $1,403.49 | $2,499.71 | $4,878.37 |