- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,778.28 / $2,187.76
| Professional | | $1,548.82 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $1,995.26
| Professional | | $1,584.89 | $1,778.28 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,511.89 / $3,311.31
| Professional | | $2,187.76 | $2,511.89 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,659.59
| Facility | | $933.25 | $933.25 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $1,778.28
| Professional | | $933.25 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |