- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.74 / $1,384.74 / $1,597.78
| Professional | | $1,384.74 | $1,384.74 | $1,597.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $1,547.24 / $2,183.10
| Professional | | $1,547.24 | $1,547.24 | $2,183.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.51 / $2,119.51 / $2,119.51
| Facility | | $2,119.51 | $2,119.51 | $2,119.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.24 / $2,119.51 / $2,183.10
| Professional | | $1,547.24 | $2,119.51 | $2,183.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.58 / $2,132.50 / $3,280.45
| Professional | | $1,252.58 | $2,132.50 | $3,280.45 |