- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.18 / $1,826.18 / $2,107.13
| Professional | | $1,826.18 | $1,826.18 | $2,107.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $2,750.50
| Facility | | $2,677.88 | $2,677.88 | $2,750.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,110.66 / $2,854.76
| Professional | | $1,954.85 | $2,110.66 | $2,854.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $2,750.50
| Facility | | $2,677.88 | $2,677.88 | $2,750.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,677.88 / $2,854.76
| Professional | | $1,954.85 | $2,677.88 | $2,854.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.43 / $2,216.77 / $4,326.20
| Professional | | $1,294.43 | $2,216.77 | $4,326.20 |