- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $3,311.31
| Professional | | $1,479.11 | $1,949.84 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $5,754.40
| Facility | | $2,570.40 | $2,570.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $4,466.84
| Professional | | $1,862.09 | $1,862.09 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $4,365.16
| Facility | | $2,137.96 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $2,454.71
| Professional | | $1,071.52 | $1,621.81 | $2,454.71 |