- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.92 / $1,437.92 / $1,670.95
| Professional | | $1,437.92 | $1,437.92 | $1,670.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.98 / $2,221.61 / $2,250.13
| Professional | | $1,878.98 | $2,221.61 | $2,250.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.13 / $2,010.03 / $2,527.46
| Professional | | $1,990.13 | $2,010.03 | $2,527.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.92 / $1,670.95 / $2,009.60
| Facility | | $1,437.92 | $1,670.95 | $2,009.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.97 / $800.61 / $10,207.25
| Professional | | $642.97 | $800.61 | $10,207.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.12 / $683.92 / $1,601.21
| Professional | | $604.12 | $683.92 | $1,601.21 |