- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,612.34 / $1,612.34 / $1,860.40
| Professional | | $1,612.34 | $1,612.34 | $1,860.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.44 / $2,571.77 / $2,571.77
| Facility | | $2,428.44 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,429.94 / $2,648.92
| Professional | | $1,877.39 | $2,429.94 | $2,648.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.44 / $2,571.77 / $2,571.77
| Facility | | $2,428.44 | $2,571.77 | $2,571.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,571.77 / $2,648.92
| Professional | | $1,877.39 | $2,571.77 | $2,648.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.85 / $1,957.21 / $3,819.64
| Professional | | $1,142.85 | $1,957.21 | $3,819.64 |