- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.79 / $1,770.78 / $1,770.78
| Professional | | $1,245.79 | $1,770.78 | $1,770.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.38 / $1,514.46 / $1,973.91
| Professional | | $1,425.38 | $1,514.46 | $1,973.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $1,932.47
| Facility | | $1,482.94 | $1,482.94 | $1,932.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,260.50 / $1,482.94
| Professional | | $1,260.50 | $1,260.50 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,128.76 / $2,128.76 / $2,128.76
| Professional | | $2,128.76 | $2,128.76 | $2,128.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.43 / $1,770.78 / $1,770.78
| Professional | | $1,480.43 | $1,770.78 | $1,770.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.46 / $1,311.69 / $3,016.49
| Professional | | $874.46 | $1,311.69 | $3,016.49 |