- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.59 / $1,613.59 / $1,861.84
| Professional | | $1,613.59 | $1,613.59 | $1,861.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,430.32 / $2,561.34 / $2,561.34
| Facility | | $2,430.32 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,411.35 / $2,730.51
| Professional | | $1,869.78 | $2,411.35 | $2,730.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,430.32 / $2,561.34 / $2,561.34
| Facility | | $2,430.32 | $2,561.34 | $2,561.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.78 / $2,561.34 / $2,730.51
| Professional | | $1,869.78 | $2,561.34 | $2,730.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.75 / $2,422.69 / $3,822.59
| Professional | | $1,099.75 | $2,422.69 | $3,822.59 |