- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.66 / $2,010.57 / $2,171.03
| Professional | | $1,823.66 | $2,010.57 | $2,171.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,468.80
| Facility | | $1,440.00 | $1,440.00 | $1,468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.00 / $1,224.00 / $1,468.00
| Professional | | $1,224.00 | $1,224.00 | $1,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.04 / $2,260.04 / $2,260.04
| Professional | | $2,260.04 | $2,260.04 | $2,260.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.86 / $1,420.47 / $1,774.57
| Professional | | $1,055.86 | $1,420.47 | $1,774.57 |