- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.59 / $1,588.40 / $2,132.48
| Professional | | $1,091.59 | $1,588.40 | $2,132.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,245.57 / $2,626.16 / $2,626.16
| Professional | | $2,245.57 | $2,626.16 | $2,626.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,918.38 / $2,225.09 / $2,225.09
| Facility | | $1,918.38 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $3,768.75
| Professional | | $246.17 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.68 / $1,689.61 / $3,135.75
| Facility | | $317.68 | $1,689.61 | $3,135.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.00 / $2,026.00 / $2,026.00
| Professional | | $2,026.00 | $2,026.00 | $2,026.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.56 / $1,157.28 / $1,752.06
| Professional | | $1,106.56 | $1,157.28 | $1,752.06 |