- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.24 / $1,636.24 / $1,887.97
| Professional | | $1,636.24 | $1,636.24 | $1,887.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $2,464.42
| Facility | | $1,743.07 | $1,743.07 | $2,464.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $1,737.34
| Professional | | $1,272.44 | $1,272.44 | $1,737.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,743.07 / $1,743.07 / $2,464.42
| Facility | | $1,743.07 | $1,743.07 | $2,464.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.44 / $1,272.44 / $1,737.34
| Professional | | $1,272.44 | $1,272.44 | $1,737.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.18 / $2,096.83 / $3,876.25
| Professional | | $1,115.18 | $2,096.83 | $3,876.25 |