- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.18 / $1,966.48 / $1,988.58
| Professional | | $1,194.18 | $1,966.48 | $1,988.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.13 / $1,921.13 / $1,921.13
| Professional | | $1,921.13 | $1,921.13 | $1,921.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,111.63
| Facility | | $1,772.06 | $1,772.06 | $2,111.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $2,831.25
| Professional | | $1,772.06 | $1,772.06 | $2,831.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.43 / $989.91 / $1,791.25
| Facility | | $131.43 | $989.91 | $1,791.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.67 / $1,252.71 / $1,925.86
| Professional | | $815.67 | $1,252.71 | $1,925.86 |