- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.59 / $1,531.55 / $1,632.85
| Professional | | $1,371.59 | $1,531.55 | $1,632.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,111.63
| Facility | | $1,772.06 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.25 / $1,506.25 / $2,111.63
| Professional | | $1,506.25 | $1,506.25 | $2,111.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.84 / $1,131.32 / $2,022.42
| Facility | | $150.84 | $1,131.32 | $2,022.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.92 / $1,234.36 / $1,769.00
| Professional | | $822.92 | $1,234.36 | $1,769.00 |