- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.76 / $1,657.76 / $1,912.80
| Professional | | $1,657.76 | $1,657.76 | $1,912.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,496.85
| Facility | | $2,017.28 | $2,017.28 | $2,496.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $2,017.28 / $2,077.80
| Professional | | $1,472.61 | $2,017.28 | $2,077.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,017.28 / $2,017.28 / $2,496.85
| Facility | | $2,017.28 | $2,017.28 | $2,496.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.61 / $2,017.28 / $2,077.80
| Professional | | $1,472.61 | $2,017.28 | $2,077.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.42 / $2,706.74 / $2,824.65
| Professional | | $1,462.42 | $2,706.74 | $2,824.65 |