- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,685.11 / $1,685.11 / $1,685.11
| Facility | | $1,685.11 | $1,685.11 | $1,685.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.33 / $1,465.41 / $2,016.92
| Professional | | $1,172.33 | $1,465.41 | $2,016.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $911.31 / $1,369.96 / $2,107.98
| Facility | | $911.31 | $1,369.96 | $2,107.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.04 / $1,730.45 / $5,609.51
| Professional | | $893.04 | $1,730.45 | $5,609.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.39 / $1,524.07 / $1,799.67
| Professional | | $848.39 | $1,524.07 | $1,799.67 |