- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.78 / $1,550.78 / $2,082.48
| Professional | | $1,550.78 | $1,550.78 | $2,082.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,925.41 / $4,984.64 / $5,009.57
| Professional | | $3,925.41 | $4,984.64 | $5,009.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.73 / $2,545.73 / $3,182.17
| Professional | | $2,545.73 | $2,545.73 | $3,182.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,329.24 / $1,595.09 / $2,082.48
| Facility | | $1,329.24 | $1,595.09 | $2,082.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.24 / $2,835.71 / $11,032.69
| Professional | | $1,329.24 | $2,835.71 | $11,032.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.40 / $2,835.71 / $3,407.29
| Professional | | $2,215.40 | $2,835.71 | $3,407.29 |