- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.65 / $2,100.40 / $2,147.50
| Professional | | $1,586.65 | $2,100.40 | $2,147.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.46 / $1,984.08 / $1,984.08
| Professional | | $1,685.46 | $1,984.08 | $1,984.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $1,208.78
| Facility | | $1,208.78 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.46 / $1,208.78 / $1,208.78
| Professional | | $1,027.46 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,543.16 / $1,543.16 / $1,543.16
| Facility | | $1,543.16 | $1,543.16 | $1,543.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.16 / $1,543.16 / $1,543.16
| Professional | | $1,543.16 | $1,543.16 | $1,543.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.80 / $1,243.16 / $1,670.81
| Professional | | $860.80 | $1,243.16 | $1,670.81 |