- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.93 / $1,013.93 / $1,585.41
| Professional | | $1,013.93 | $1,013.93 | $1,585.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,768.15 / $1,768.15 / $1,768.15
| Facility | | $1,768.15 | $1,768.15 | $1,768.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.15 / $1,768.15 / $1,768.15
| Professional | | $1,768.15 | $1,768.15 | $1,768.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,162.20 / $1,162.20 / $1,960.31
| Facility | | $1,162.20 | $1,162.20 | $1,960.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.41 / $848.41 / $1,162.20
| Professional | | $848.41 | $848.41 | $1,162.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.40 / $798.17 / $886.12
| Professional | | $721.40 | $798.17 | $886.12 |