- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,606.45 / $1,733.69 / $1,845.03
| Professional | | $1,606.45 | $1,733.69 | $1,845.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,115.96 / $2,115.96 / $2,115.96
| Facility | | $2,115.96 | $2,115.96 | $2,115.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $2,115.96 / $2,115.96
| Professional | | $1,590.54 | $2,115.96 | $2,115.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $2,115.96 / $2,319.88
| Facility | | $1,590.54 | $2,115.96 | $2,319.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.59 / $1,725.59 / $2,250.77
| Professional | | $1,725.59 | $1,725.59 | $2,250.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |