- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.60 / $1,230.08 / $1,284.67
| Professional | | $1,133.60 | $1,230.08 | $1,284.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.13 / $2,084.13 / $2,084.13
| Facility | | $2,084.13 | $2,084.13 | $2,084.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.41 / $1,521.41 / $2,084.13
| Professional | | $1,521.41 | $1,521.41 | $2,084.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.19 / $1,815.91 / $1,815.91
| Facility | | $2.19 | $1,815.91 | $1,815.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.13 / $1,449.02 / $2,070.03
| Professional | | $916.13 | $1,449.02 | $2,070.03 |