- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.25 / $1,858.25 / $2,144.13
| Professional | | $1,858.25 | $1,858.25 | $2,144.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,798.81
| Facility | | $2,050.41 | $2,050.41 | $2,798.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $1,778.66
| Professional | | $1,496.80 | $1,496.80 | $1,778.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,798.81
| Facility | | $2,050.41 | $2,050.41 | $2,798.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $1,778.66
| Professional | | $1,496.80 | $1,496.80 | $1,778.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.50 / $2,255.71 / $4,402.18
| Professional | | $1,266.50 | $2,255.71 | $4,402.18 |