- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.51 / $1,813.51 / $2,092.51
| Professional | | $1,813.51 | $1,813.51 | $2,092.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,731.42
| Facility | | $2,463.07 | $2,463.07 | $2,731.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,118.35 / $2,625.75
| Professional | | $1,798.04 | $2,118.35 | $2,625.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,463.07 / $2,463.07 / $2,731.42
| Facility | | $2,463.07 | $2,463.07 | $2,731.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.04 / $2,463.07 / $2,625.75
| Professional | | $1,798.04 | $2,463.07 | $2,625.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.00 / $2,556.73 / $4,296.18
| Professional | | $1,236.00 | $2,556.73 | $4,296.18 |