- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.49 / $1,761.66 / $2,073.31
| Professional | | $1,623.49 | $1,761.66 | $2,073.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $2,481.10
| Facility | | $2,481.10 | $2,481.10 | $2,481.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $1,811.20 / $2,481.10
| Professional | | $1,811.20 | $1,811.20 | $2,481.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.14 / $2,600.65 / $2,600.65
| Facility | | $3.14 | $2,600.65 | $2,600.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,776.97 / $2,223.42 / $3,280.06
| Professional | | $1,776.97 | $2,223.42 | $3,280.06 |