- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.42 / $1,203.42 / $2,181.37
| Professional | | $1,203.42 | $1,203.42 | $2,181.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,336.73 / $2,336.73 / $2,336.73
| Professional | | $2,336.73 | $2,336.73 | $2,336.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $3,037.72
| Facility | | $1,772.06 | $1,772.06 | $3,037.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.06 / $1,772.06 / $1,772.06
| Professional | | $1,772.06 | $1,772.06 | $1,772.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $179.12 / $909.48 / $1,791.25
| Facility | | $179.12 | $909.48 | $1,791.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.85 / $1,206.46 / $1,814.40
| Professional | | $1,020.85 | $1,206.46 | $1,814.40 |