- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.58 / $1,700.58 / $1,962.21
| Professional | | $1,700.58 | $1,700.58 | $1,962.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $2,561.34
| Facility | | $2,479.82 | $2,479.82 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $2,051.46 / $2,554.21
| Professional | | $1,810.27 | $2,051.46 | $2,554.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $2,561.34
| Facility | | $2,479.82 | $2,479.82 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $2,479.82 / $2,554.21
| Professional | | $1,810.27 | $2,479.82 | $2,554.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.41 / $2,618.90 / $4,028.68
| Professional | | $1,205.41 | $2,618.90 | $4,028.68 |