- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.21 / $1,658.21 / $1,913.32
| Professional | | $1,658.21 | $1,658.21 | $1,913.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $2,497.52
| Facility | | $2,482.86 | $2,482.86 | $2,497.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $2,482.86 / $2,646.85
| Professional | | $1,812.49 | $2,482.86 | $2,646.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $2,497.52
| Facility | | $2,482.86 | $2,482.86 | $2,497.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $2,482.86 / $2,646.85
| Professional | | $1,812.49 | $2,482.86 | $2,646.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.50 / $2,182.50 / $2,615.05
| Facility | | $2,182.50 | $2,182.50 | $2,615.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.16 / $2,012.89 / $3,928.29
| Professional | | $1,130.16 | $2,012.89 | $3,928.29 |