- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.20 / $1,769.92 / $1,849.70
| Professional | | $1,632.20 | $1,769.92 | $1,849.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $2,282.71 / $2,282.71
| Facility | | $2,282.71 | $2,282.71 | $2,282.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.39 / $1,666.39 / $1,666.39
| Professional | | $1,666.39 | $1,666.39 | $1,666.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.23 / $1,982.23 / $1,982.23
| Facility | | $1,982.23 | $1,982.23 | $1,982.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.49 / $2,119.96 / $2,980.46
| Professional | | $1,786.49 | $2,119.96 | $2,980.46 |