- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $2,137.96
| Professional | | $1,380.38 | $1,819.70 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,630.78
| Professional | | $3,090.30 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $2,187.76
| Professional | | $1,096.48 | $2,137.96 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $1,513.56 / $2,238.72
| Professional | | $50.12 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $5,495.41
| Professional | | $870.96 | $1,047.13 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,513.56 / $1,513.56
| Professional | | $676.08 | $1,513.56 | $1,513.56 |