- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.55 / $2,106.55 / $2,430.63
| Professional | | $2,106.55 | $2,106.55 | $2,430.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $3,172.77
| Facility | | $3,060.59 | $3,060.59 | $3,172.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $2,460.44
| Professional | | $2,234.23 | $2,234.23 | $2,460.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.59 / $3,060.59 / $3,172.77
| Facility | | $3,060.59 | $3,060.59 | $3,172.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.23 / $2,234.23 / $2,460.44
| Professional | | $2,234.23 | $2,234.23 | $2,460.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,889.95 / $3,589.32 / $3,589.32
| Professional | | $1,889.95 | $3,589.32 | $3,589.32 |