- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.58 / $1,030.58 / $1,189.14
| Professional | | $1,030.58 | $1,030.58 | $1,189.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.63 / $1,708.63 / $1,708.63
| Professional | | $1,708.63 | $1,708.63 | $1,708.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $1,552.22
| Facility | | $1,207.83 | $1,207.83 | $1,552.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $1,207.83 / $1,287.59
| Professional | | $881.72 | $1,207.83 | $1,287.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $1,552.22
| Facility | | $1,207.83 | $1,207.83 | $1,552.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $1,207.83 / $1,287.59
| Professional | | $881.72 | $1,207.83 | $1,287.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.55 / $1,055.55 / $1,055.55
| Facility | | $1,055.55 | $1,055.55 | $1,055.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.50 / $1,587.11 / $2,441.46
| Professional | | $730.50 | $1,587.11 | $2,441.46 |