- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.71 / $1,732.32 / $1,732.32
| Professional | | $1,162.71 | $1,732.32 | $1,732.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.58 / $1,886.50 / $1,886.50
| Professional | | $1,487.58 | $1,886.50 | $1,886.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.06 / $1,717.06 / $1,717.06
| Facility | | $1,717.06 | $1,717.06 | $1,717.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.71 / $1,417.56 / $1,759.99
| Professional | | $163.71 | $1,417.56 | $1,759.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.71 / $1,538.99 / $1,732.32
| Professional | | $1,162.71 | $1,538.99 | $1,732.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.89 / $1,540.12 / $2,880.76
| Professional | | $1,008.89 | $1,540.12 | $2,880.76 |