- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.52 / $1,549.17 / $1,595.42
| Professional | | $1,152.52 | $1,549.17 | $1,595.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.54 / $1,656.50 / $1,997.01
| Professional | | $1,618.54 | $1,656.50 | $1,997.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- 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
- $264.06 / $264.06 / $264.06
| Professional | | $264.06 | $264.06 | $264.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.34 / $1,123.40 / $1,872.33
| Professional | | $767.34 | $1,123.40 | $1,872.33 |