- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,905.46
| Professional | | $933.25 | $1,071.52 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $2,454.71
| Facility | | $1,548.82 | $1,548.82 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,949.84
| Professional | | $1,122.02 | $1,122.02 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $954.99 / $1,778.28
| Facility | | $724.44 | $954.99 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $977.24 / $1,445.44
| Professional | | $870.96 | $977.24 | $1,445.44 |