- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.31 / $2,136.26 / $2,136.26
| Professional | | $1,671.31 | $2,136.26 | $2,136.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.35 / $2,117.36 / $2,382.03
| Professional | | $1,323.35 | $2,117.36 | $2,382.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.02 / $1,332.02 / $1,332.02
| Professional | | $1,332.02 | $1,332.02 | $1,332.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,683.88 / $2,513.25 / $4,626.34
| Facility | | $1,683.88 | $2,513.25 | $4,626.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,055.57 / $13,612.50
| Professional | | $1,055.57 | $1,055.57 | $13,612.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,055.57 / $1,507.95
| Professional | | $1,055.57 | $1,055.57 | $1,507.95 |