- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,454.71 / $3,467.37
| Professional | | $1,122.02 | $2,454.71 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,467.37 / $4,265.80
| Professional | | $3,162.28 | $3,467.37 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $5,370.32
| Professional | | $1,905.46 | $2,630.27 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,238.72 / $4,073.80
| Professional | | $1,995.26 | $2,238.72 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,344.23 / $5,128.61
| Professional | | $1,479.11 | $2,344.23 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |