- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.86 / $1,481.86 / $1,709.84
| Professional | | $1,481.86 | $1,481.86 | $1,709.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,654.54 / $2,231.91
| Facility | | $1,654.54 | $1,654.54 | $2,231.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.81 / $1,566.65 / $1,763.81
| Professional | | $1,207.81 | $1,566.65 | $1,763.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,654.54 / $1,654.54 / $2,231.91
| Facility | | $1,654.54 | $1,654.54 | $2,231.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.81 / $1,654.54 / $1,763.81
| Professional | | $1,207.81 | $1,654.54 | $1,763.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.36 / $1,798.82 / $3,510.53
| Professional | | $1,050.36 | $1,798.82 | $3,510.53 |