- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $1,995.26
| Professional | | $1,047.13 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,089.30
| Facility | | $1,778.28 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,818.38
| Professional | | $1,513.56 | $1,778.28 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $912.01 / $1,862.09
| Facility | | $117.49 | $912.01 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $1,949.84
| Professional | | $812.83 | $1,258.93 | $1,949.84 |