- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.72 / $1,624.72 / $1,874.68
| Professional | | $1,624.72 | $1,624.72 | $1,874.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $2,447.07
| Facility | | $2,253.75 | $2,253.75 | $2,447.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.24 / $1,915.69 / $2,321.36
| Professional | | $1,838.24 | $1,915.69 | $2,321.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $2,447.07
| Facility | | $2,253.75 | $2,253.75 | $2,447.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.24 / $2,253.75 / $2,321.36
| Professional | | $1,838.24 | $2,253.75 | $2,321.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.33 / $2,218.57 / $3,848.96
| Professional | | $1,107.33 | $2,218.57 | $3,848.96 |