- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,388.87 / $1,388.87 / $1,602.54
| Professional | | $1,388.87 | $1,388.87 | $1,602.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $2,091.86
| Facility | | $1,769.38 | $1,769.38 | $2,091.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,769.38 / $1,822.46
| Professional | | $1,291.65 | $1,769.38 | $1,822.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.38 / $1,769.38 / $2,091.86
| Facility | | $1,769.38 | $1,769.38 | $2,091.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.65 / $1,769.38 / $1,822.46
| Professional | | $1,291.65 | $1,769.38 | $1,822.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.59 / $1,823.00 / $3,290.23
| Professional | | $946.59 | $1,823.00 | $3,290.23 |