- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,230.27
| Professional | | $1,174.90 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $2,754.23
| Professional | | $954.99 | $1,479.11 | $2,754.23 |
- 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 / $2,089.30
| Professional | | $1,513.56 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $1,122.02 / $1,513.56
| Facility | | $151.36 | $1,122.02 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $2,290.87
| Professional | | $977.24 | $1,348.96 | $2,290.87 |