- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.06 / $2,111.53 / $2,158.90
| Professional | | $1,595.06 | $2,111.53 | $2,158.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.29 / $2,074.35 / $2,074.35
| Professional | | $1,636.29 | $2,074.35 | $2,074.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,414.26
| Facility | | $213.28 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.28 / $1,202.11 / $1,760.73
| Professional | | $213.28 | $1,202.11 | $1,760.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.37 / $1,613.37 / $1,613.37
| Professional | | $1,613.37 | $1,613.37 | $1,613.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.66 / $1,455.30 / $2,209.46
| Professional | | $1,146.66 | $1,455.30 | $2,209.46 |