- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,553.76 / $1,553.76 / $1,642.78
| Professional | | $1,553.76 | $1,553.76 | $1,642.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.86 / $1,623.86 / $1,910.52
| Professional | | $1,623.86 | $1,623.86 | $1,910.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,436.52 / $1,436.52 / $2,532.06
| Facility | | $1,436.52 | $1,436.52 | $2,532.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,436.52 / $1,640.47
| Professional | | $183.43 | $1,436.52 | $1,640.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,116.39 / $2,116.39 / $2,116.39
| Professional | | $2,116.39 | $2,116.39 | $2,116.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.08 / $1,553.76 / $1,642.78
| Professional | | $1,091.08 | $1,553.76 | $1,642.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.92 / $1,271.88 / $2,323.38
| Professional | | $847.92 | $1,271.88 | $2,323.38 |