- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.36 / $1,353.13 / $4,832.59
| Professional | | $1,003.36 | $1,353.13 | $4,832.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,483.81 / $1,483.81 / $1,483.81
| Facility | | $1,483.81 | $1,483.81 | $1,483.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $747.06 / $1,483.81 / $1,486.43
| Professional | | $747.06 | $1,483.81 | $1,486.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $725.81 / $997.99 / $1,483.81
| Facility | | $725.81 | $997.99 | $1,483.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.53 / $1,483.81 / $1,978.90
| Professional | | $914.53 | $1,483.81 | $1,978.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.46 / $1,473.78 / $1,678.37
| Professional | | $1,230.46 | $1,473.78 | $1,678.37 |