- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,870.38 / $1,870.38 / $2,158.13
| Professional | | $1,870.38 | $1,870.38 | $2,158.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $2,817.08
| Facility | | $2,540.30 | $2,540.30 | $2,817.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $2,184.65 / $2,616.51
| Professional | | $1,854.42 | $2,184.65 | $2,616.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,540.30 / $2,540.30 / $2,817.08
| Facility | | $2,540.30 | $2,540.30 | $2,817.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.42 / $2,540.30 / $2,616.51
| Professional | | $1,854.42 | $2,540.30 | $2,616.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.76 / $2,636.90 / $4,430.92
| Professional | | $1,274.76 | $2,636.90 | $4,430.92 |