- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.24 / $1,070.24 / $1,874.28
| Professional | | $1,070.24 | $1,070.24 | $1,874.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.31 / $2,090.31 / $2,090.31
| Facility | | $2,090.31 | $2,090.31 | $2,090.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.31 / $2,090.31 / $2,090.31
| Professional | | $2,090.31 | $2,090.31 | $2,090.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,018.60 / $2,099.48
| Facility | | $1,018.60 | $1,018.60 | $2,099.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $1,618.44
| Professional | | $743.58 | $743.58 | $1,618.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.02 / $813.25 / $1,253.19
| Professional | | $735.02 | $813.25 | $1,253.19 |