- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.62 / $2,080.19 / $2,126.80
| Professional | | $1,460.62 | $2,080.19 | $2,126.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.18 / $1,997.01 / $1,997.01
| Professional | | $1,550.18 | $1,997.01 | $1,997.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.68 / $1,639.62 / $1,639.62
| Professional | | $1,393.68 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.60 / $1,231.32 / $1,654.90
| Professional | | $852.60 | $1,231.32 | $1,654.90 |