- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.36 / $1,548.94 / $2,013.06
| Professional | | $728.36 | $1,548.94 | $2,013.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.33 / $1,937.33 / $1,937.33
| Professional | | $1,937.33 | $1,937.33 | $1,937.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,018.05 / $2,018.05 / $2,018.05
| Facility | | $2,018.05 | $2,018.05 | $2,018.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,018.05 / $2,018.05 / $2,018.05
| Professional | | $2,018.05 | $2,018.05 | $2,018.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $2,520.11
| Facility | | $1,460.50 | $1,460.50 | $2,520.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $1,916.91
| Professional | | $1,241.43 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.25 / $1,201.69 / $2,115.91
| Professional | | $730.25 | $1,201.69 | $2,115.91 |