- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,362.46 / $1,434.25 / $1,544.01
| Professional | | $1,362.46 | $1,434.25 | $1,544.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,482.86 / $2,482.86 / $2,482.86
| Facility | | $2,482.86 | $2,482.86 | $2,482.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,812.49 / $1,812.49 / $2,482.86
| Professional | | $1,812.49 | $1,812.49 | $2,482.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.64 / $2,182.50 / $2,182.50
| Facility | | $2.64 | $2,182.50 | $2,182.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.25 / $1,659.02 / $2,487.91
| Professional | | $1,491.25 | $1,659.02 | $2,487.91 |