- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,853.35 / $1,853.35 / $2,392.92
| Professional | | $1,853.35 | $1,853.35 | $2,392.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.05 / $1,936.05 / $2,279.06
| Professional | | $1,936.05 | $1,936.05 | $2,279.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $3,020.16
| Facility | | $1,406.76 | $1,406.76 | $3,020.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $1,956.94
| Professional | | $218.80 | $1,406.76 | $1,956.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,524.46 / $2,524.46 / $2,524.46
| Professional | | $2,524.46 | $2,524.46 | $2,524.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.55 / $1,853.35 / $2,392.92
| Professional | | $1,301.55 | $1,853.35 | $2,392.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.49 / $1,873.82 / $3,344.76
| Professional | | $1,011.49 | $1,873.82 | $3,344.76 |