- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.01 / $1,357.87 / $5,062.17
| Professional | | $1,034.01 | $1,357.87 | $5,062.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.12 / $1,541.12 / $1,541.12
| Professional | | $1,541.12 | $1,541.12 | $1,541.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.12 / $1,541.12 / $1,541.12
| Facility | | $1,541.12 | $1,541.12 | $1,541.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.68 / $1,541.12 / $1,623.78
| Professional | | $823.68 | $1,541.12 | $1,623.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.82 / $1,048.86 / $1,541.12
| Facility | | $762.82 | $1,048.86 | $1,541.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.00 / $1,541.12 / $2,016.70
| Professional | | $932.00 | $1,541.12 | $2,016.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.87 / $1,613.56 / $1,846.03
| Professional | | $1,369.87 | $1,613.56 | $1,846.03 |