- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.74 / $1,093.74 / $1,915.44
| Professional | | $1,093.74 | $1,093.74 | $1,915.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,136.21 / $2,136.21 / $2,136.21
| Facility | | $2,136.21 | $2,136.21 | $2,136.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.21 / $2,136.21 / $2,136.21
| Professional | | $2,136.21 | $2,136.21 | $2,136.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $2,368.44
| Facility | | $1,207.83 | $1,207.83 | $2,368.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $881.72 / $1,207.83
| Professional | | $881.72 | $881.72 | $1,207.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.58 / $1,285.78 / $1,486.00
| Professional | | $871.58 | $1,285.78 | $1,486.00 |