- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.74 / $1,836.74 / $2,119.31
| Professional | | $1,836.74 | $1,836.74 | $2,119.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,766.42
| Facility | | $2,326.75 | $2,326.75 | $2,766.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,145.73 / $2,480.44
| Professional | | $1,698.53 | $2,145.73 | $2,480.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.75 / $2,326.75 / $2,766.42
| Facility | | $2,326.75 | $2,326.75 | $2,766.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.53 / $2,326.75 / $2,480.44
| Professional | | $1,698.53 | $2,326.75 | $2,480.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.84 / $2,229.61 / $4,351.22
| Professional | | $1,251.84 | $2,229.61 | $4,351.22 |