- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,318.26 / $2,290.87
| Professional | | $1,230.27 | $1,318.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $2,238.72
| Facility | | $1,445.44 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $831.76 / $1,737.80
| Facility | | $83.18 | $831.76 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,737.80
| Professional | | $933.25 | $1,122.02 | $1,737.80 |