- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.91 / $1,945.91 / $2,245.28
| Professional | | $1,945.91 | $1,945.91 | $2,245.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $2,476.09 / $2,930.84
| Facility | | $2,476.09 | $2,476.09 | $2,930.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $2,275.89 / $2,550.37
| Professional | | $1,807.55 | $2,275.89 | $2,550.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,476.09 / $2,476.09 / $2,930.84
| Facility | | $2,476.09 | $2,476.09 | $2,930.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,807.55 / $2,476.09 / $2,550.37
| Professional | | $1,807.55 | $2,476.09 | $2,550.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.29 / $2,996.70 / $4,609.85
| Professional | | $1,379.29 | $2,996.70 | $4,609.85 |