- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.69 / $1,017.69 / $1,782.25
| Professional | | $1,017.69 | $1,017.69 | $1,782.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,987.68 / $1,987.68 / $1,987.68
| Facility | | $1,987.68 | $1,987.68 | $1,987.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,987.68 / $1,987.68 / $1,987.68
| Professional | | $1,987.68 | $1,987.68 | $1,987.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,271.83 / $2,688.02
| Facility | | $1,271.83 | $1,271.83 | $2,688.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $928.44 / $1,271.83
| Professional | | $928.44 | $928.44 | $1,271.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.76 / $1,353.90 / $1,564.74
| Professional | | $917.76 | $1,353.90 | $1,564.74 |