- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.11 / $1,630.86 / $6,091.69
| Professional | | $1,244.11 | $1,630.86 | $6,091.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,851.87 / $1,851.87 / $1,851.87
| Facility | | $1,851.87 | $1,851.87 | $1,851.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.38 / $1,851.87 / $1,962.50
| Professional | | $991.38 | $1,851.87 | $1,962.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $916.40 / $1,260.05 / $1,851.87
| Facility | | $916.40 | $1,260.05 | $1,851.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.28 / $1,851.87 / $2,424.10
| Professional | | $1,120.28 | $1,851.87 | $2,424.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.02 / $1,921.47 / $2,157.42
| Professional | | $1,633.02 | $1,921.47 | $2,157.42 |