- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.39 / $1,777.39 / $2,050.83
| Professional | | $1,777.39 | $1,777.39 | $2,050.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.02 / $3,141.52 / $3,141.52
| Facility | | $2,677.02 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.25 / $2,878.19 / $3,235.77
| Professional | | $2,268.25 | $2,878.19 | $3,235.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.02 / $3,141.52 / $3,141.52
| Facility | | $2,677.02 | $3,141.52 | $3,141.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,268.25 / $3,141.52 / $3,235.77
| Professional | | $2,268.25 | $3,141.52 | $3,235.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.39 / $2,737.18 / $4,210.63
| Professional | | $1,211.39 | $2,737.18 | $4,210.63 |