- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.85 / $2,006.49 / $2,286.46
| Professional | | $1,493.85 | $2,006.49 | $2,286.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.54 / $1,739.72 / $1,739.72
| Professional | | $1,600.54 | $1,739.72 | $1,739.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $2,491.32
| Facility | | $1,786.79 | $1,786.79 | $2,491.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $3,663.75
| Professional | | $1,518.77 | $1,786.79 | $3,663.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.40 / $1,332.12 / $2,121.82
| Professional | | $893.40 | $1,332.12 | $2,121.82 |