- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.33 / $1,667.33 / $1,923.84
| Professional | | $1,667.33 | $1,667.33 | $1,923.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.29 / $1,808.29 / $2,511.26
| Facility | | $1,808.29 | $1,808.29 | $2,511.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $1,802.21
| Professional | | $1,537.05 | $1,537.05 | $1,802.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,808.29 / $1,808.29 / $2,511.26
| Facility | | $1,808.29 | $1,808.29 | $2,511.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.05 / $1,537.05 / $1,802.21
| Professional | | $1,537.05 | $1,537.05 | $1,802.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.36 / $2,175.28 / $3,949.90
| Professional | | $1,136.36 | $2,175.28 | $3,949.90 |