- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.47 / $1,390.47 / $1,604.39
| Professional | | $1,390.47 | $1,390.47 | $1,604.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.76 / $1,960.76 / $2,094.26
| Facility | | $1,960.76 | $1,960.76 | $2,094.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,958.78 / $2,090.26
| Professional | | $1,431.35 | $1,958.78 | $2,090.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,960.76 / $1,960.76 / $2,094.26
| Facility | | $1,960.76 | $1,960.76 | $2,094.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.35 / $1,960.76 / $2,090.26
| Professional | | $1,431.35 | $1,960.76 | $2,090.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.58 / $2,141.32 / $3,294.01
| Professional | | $985.58 | $2,141.32 | $3,294.01 |