- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.07 / $1,107.07 / $1,938.78
| Professional | | $1,107.07 | $1,107.07 | $1,938.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,162.23 / $2,162.23 / $2,162.23
| Facility | | $2,162.23 | $2,162.23 | $2,162.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.23 / $2,162.23 / $2,162.23
| Professional | | $2,162.23 | $2,162.23 | $2,162.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.54 / $1,222.54 / $2,397.29
| Facility | | $1,222.54 | $1,222.54 | $2,397.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.45 / $892.45 / $1,942.33
| Professional | | $892.45 | $892.45 | $1,942.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.19 / $976.08 / $1,504.11
| Professional | | $882.19 | $976.08 | $1,504.11 |