- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.99 / $1,848.76 / $2,035.67
| Professional | | $1,085.99 | $1,848.76 | $2,035.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.08 / $1,747.08 / $1,747.08
| Professional | | $1,747.08 | $1,747.08 | $1,747.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $2,994.75
| Professional | | $1,460.50 | $1,460.50 | $2,994.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.25 / $1,191.48 / $1,749.02
| Professional | | $730.25 | $1,191.48 | $1,749.02 |