- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.13 / $1,908.77 / $1,975.36
| Professional | | $1,449.13 | $1,908.77 | $1,975.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.70 / $1,737.72 / $1,737.72
| Professional | | $1,598.70 | $1,737.72 | $1,737.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $2,583.51
| Facility | | $1,639.62 | $1,639.62 | $2,583.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.66 / $1,639.62 / $2,962.50
| Professional | | $188.66 | $1,639.62 | $2,962.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.93 / $1,142.59 / $1,645.78
| Professional | | $748.93 | $1,142.59 | $1,645.78 |