- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.82 / $1,804.82 / $2,082.48
| Professional | | $1,804.82 | $1,804.82 | $2,082.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,718.35
| Facility | | $2,425.11 | $2,425.11 | $2,718.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,164.30 / $2,497.86
| Professional | | $1,770.33 | $2,164.30 | $2,497.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.11 / $2,425.11 / $2,718.35
| Facility | | $2,425.11 | $2,425.11 | $2,718.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.33 / $2,425.11 / $2,497.86
| Professional | | $1,770.33 | $2,425.11 | $2,497.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.08 / $2,373.58 / $4,275.62
| Professional | | $1,230.08 | $2,373.58 | $4,275.62 |