- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.74 / $1,882.82 / $2,033.03
| Professional | | $1,707.74 | $1,882.82 | $2,033.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.74 / $1,195.75 / $1,406.76
| Professional | | $229.74 | $1,195.75 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,065.81 / $2,065.81 / $2,065.81
| Professional | | $2,065.81 | $2,065.81 | $2,065.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.84 / $1,330.27 / $1,661.80
| Professional | | $886.84 | $1,330.27 | $1,661.80 |