- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.82 / $1,452.40 / $5,203.10
| Professional | | $1,078.82 | $1,452.40 | $5,203.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.33 / $1,596.33 / $1,596.33
| Professional | | $1,596.33 | $1,596.33 | $1,596.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,596.33 / $1,596.33 / $1,596.33
| Facility | | $1,596.33 | $1,596.33 | $1,596.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.61 / $1,596.33 / $1,609.23
| Professional | | $818.61 | $1,596.33 | $1,609.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $780.79 / $1,073.58 / $1,596.33
| Facility | | $780.79 | $1,073.58 | $1,596.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.15 / $1,596.33 / $2,125.19
| Professional | | $982.15 | $1,596.33 | $2,125.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.74 / $1,587.20 / $1,804.44
| Professional | | $1,327.74 | $1,587.20 | $1,804.44 |