- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,135.41 / $2,135.41 / $2,463.94
| Professional | | $2,135.41 | $2,135.41 | $2,463.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,502.67 / $2,502.67 / $3,216.26
| Facility | | $2,502.67 | $2,502.67 | $3,216.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.95 / $2,494.55 / $2,667.97
| Professional | | $1,826.95 | $2,494.55 | $2,667.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,502.67 / $2,502.67 / $3,216.26
| Facility | | $2,502.67 | $2,502.67 | $3,216.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.95 / $2,502.67 / $2,667.97
| Professional | | $1,826.95 | $2,502.67 | $2,667.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.61 / $2,592.16 / $5,058.79
| Professional | | $1,513.61 | $2,592.16 | $5,058.79 |