- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.55 / $1,954.76 / $2,443.44
| Professional | | $1,843.55 | $1,954.76 | $2,443.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $915.38 / $1,675.09 / $2,424.61
| Facility | | $915.38 | $1,675.09 | $2,424.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,110.00 / $4,110.00 / $4,110.00
| Professional | | $4,110.00 | $4,110.00 | $4,110.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,372.29 / $1,372.29 / $1,564.00
| Facility | | $1,372.29 | $1,372.29 | $1,564.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.00 / $1,372.29 / $1,826.64
| Professional | | $1,271.00 | $1,372.29 | $1,826.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.58 / $1,521.28 / $1,546.72
| Professional | | $1,080.58 | $1,521.28 | $1,546.72 |