- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.74 / $1,370.74 / $1,449.27
| Professional | | $1,370.74 | $1,370.74 | $1,449.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.98 / $1,431.98 / $1,685.57
| Professional | | $1,431.98 | $1,431.98 | $1,685.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $2,233.78
| Facility | | $975.26 | $975.26 | $2,233.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $975.26 / $1,188.00
| Professional | | $161.82 | $975.26 | $1,188.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.10 / $1,867.10 / $1,867.10
| Professional | | $1,867.10 | $1,867.10 | $1,867.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.61 / $1,370.74 / $1,449.27
| Professional | | $962.61 | $1,370.74 | $1,449.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.67 / $1,122.13 / $2,049.82
| Professional | | $643.67 | $1,122.13 | $2,049.82 |