- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,612.83 / $5,594.06 / $5,594.06
| Professional | | $1,612.83 | $5,594.06 | $5,594.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.63 / $1,946.25 / $1,946.25
| Facility | | $908.63 | $1,946.25 | $1,946.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.63 / $1,946.25 / $1,946.25
| Professional | | $908.63 | $1,946.25 | $1,946.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $810.71 / $1,853.57 / $1,946.25
| Facility | | $810.71 | $1,853.57 | $1,946.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.63 / $1,460.75 / $1,947.66
| Professional | | $908.63 | $1,460.75 | $1,947.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.67 / $725.45 / $1,117.90
| Professional | | $655.67 | $725.45 | $1,117.90 |