- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.07 / $1,382.07 / $1,594.70
| Professional | | $1,382.07 | $1,382.07 | $1,594.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,291.35 / $2,291.35 / $2,291.35
| Professional | | $2,291.35 | $2,291.35 | $2,291.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.28 / $1,327.28 / $2,081.61
| Facility | | $1,327.28 | $1,327.28 | $2,081.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.91 / $1,322.71 / $1,414.94
| Professional | | $968.91 | $1,322.71 | $1,414.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,327.28 / $1,327.28 / $2,081.61
| Facility | | $1,327.28 | $1,327.28 | $2,081.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.91 / $1,327.28 / $1,414.94
| Professional | | $968.91 | $1,327.28 | $1,414.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.96 / $1,677.68 / $3,274.11
| Professional | | $941.96 | $1,677.68 | $3,274.11 |