- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.69 / $2,350.69 / $2,712.34
| Professional | | $2,350.69 | $2,350.69 | $2,712.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $3,540.52
| Facility | | $2,801.20 | $2,801.20 | $3,540.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $2,745.83
| Professional | | $2,044.88 | $2,044.88 | $2,745.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,801.20 / $2,801.20 / $3,540.52
| Facility | | $2,801.20 | $2,801.20 | $3,540.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,044.88 / $2,044.88 / $2,745.83
| Professional | | $2,044.88 | $2,044.88 | $2,745.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.13 / $3,314.06 / $5,568.79
| Professional | | $1,602.13 | $3,314.06 | $5,568.79 |