- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.53 / $1,474.34 / $1,518.35
| Professional | | $1,128.53 | $1,474.34 | $1,518.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.57 / $1,540.35 / $1,924.11
| Professional | | $1,245.57 | $1,540.35 | $1,924.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,232.84 / $3,787.50
| Professional | | $184.74 | $1,232.84 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.30 / $251.30 / $251.30
| Professional | | $251.30 | $251.30 | $251.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.94 / $1,100.01 / $1,569.13
| Professional | | $866.94 | $1,100.01 | $1,569.13 |