- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.24 / $5,442.54 / $5,442.54
| Professional | | $1,209.24 | $5,442.54 | $5,442.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.68 / $1,664.68 / $1,664.68
| Professional | | $1,664.68 | $1,664.68 | $1,664.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.68 / $1,664.68 / $1,664.68
| Facility | | $1,664.68 | $1,664.68 | $1,664.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.33 / $1,664.68 / $1,664.68
| Professional | | $1,187.33 | $1,664.68 | $1,664.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.68 / $2,105.35 / $2,246.01
| Facility | | $1,664.68 | $2,105.35 | $2,246.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.55 / $1,450.06 / $2,214.80
| Professional | | $1,023.55 | $1,450.06 | $2,214.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.13 / $1,847.30 / $2,914.68
| Professional | | $1,628.13 | $1,847.30 | $2,914.68 |