- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,854.90 / $1,854.90 / $2,140.27
| Professional | | $1,854.90 | $1,854.90 | $2,140.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,793.77 / $2,861.13 / $2,861.13
| Facility | | $2,793.77 | $2,861.13 | $2,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.96 / $2,431.96 / $2,946.96
| Professional | | $2,004.96 | $2,431.96 | $2,946.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,793.77 / $2,861.13 / $2,861.13
| Facility | | $2,793.77 | $2,861.13 | $2,861.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.96 / $2,861.13 / $2,946.96
| Professional | | $2,004.96 | $2,861.13 | $2,946.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.22 / $2,420.00 / $4,394.26
| Professional | | $1,264.22 | $2,420.00 | $4,394.26 |