- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.91 / $1,795.55 / $2,046.09
| Professional | | $1,369.91 | $1,795.55 | $2,046.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.55 / $2,327.77 / $2,327.77
| Professional | | $2,141.55 | $2,327.77 | $2,327.77 |
- 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
- $1,506.25 / $1,772.06 / $2,831.25
| Professional | | $1,506.25 | $1,772.06 | $2,831.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.84 / $1,343.44 / $1,791.25
| Facility | | $150.84 | $1,343.44 | $1,791.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.48 / $1,314.32 / $2,004.86
| Professional | | $816.48 | $1,314.32 | $2,004.86 |