- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.10 / $1,783.10 / $2,057.42
| Professional | | $1,783.10 | $1,783.10 | $2,057.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,685.64
| Facility | | $2,264.80 | $2,264.80 | $2,685.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $2,082.79 / $2,414.39
| Professional | | $1,653.30 | $2,082.79 | $2,414.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,264.80 / $2,685.64
| Facility | | $2,264.80 | $2,264.80 | $2,685.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.30 / $2,264.80 / $2,414.39
| Professional | | $1,653.30 | $2,264.80 | $2,414.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.29 / $2,513.88 / $4,224.17
| Professional | | $1,215.29 | $2,513.88 | $4,224.17 |