- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.78 / $1,564.78 / $1,805.51
| Professional | | $1,564.78 | $1,564.78 | $1,805.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $1,784.15 / $2,356.79
| Facility | | $1,784.15 | $1,784.15 | $2,356.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,784.15 / $1,837.67
| Professional | | $1,302.43 | $1,784.15 | $1,837.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $1,784.15 / $2,356.79
| Facility | | $1,784.15 | $1,784.15 | $2,356.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,784.15 / $1,837.67
| Professional | | $1,302.43 | $1,784.15 | $1,837.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.14 / $1,899.47 / $3,706.96
| Professional | | $1,109.14 | $1,899.47 | $3,706.96 |