- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.68 / $1,816.17 / $1,870.38
| Professional | | $1,336.68 | $1,816.17 | $1,870.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.49 / $1,897.49 / $2,279.06
| Professional | | $1,897.49 | $1,897.49 | $2,279.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $3,588.75
| Professional | | $218.80 | $1,406.76 | $3,588.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.57 / $309.57 / $309.57
| Professional | | $309.57 | $309.57 | $309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.89 / $1,302.91 / $2,171.51
| Professional | | $889.89 | $1,302.91 | $2,171.51 |