- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.70 / $1,095.70 / $6,813.79
| Professional | | $1,095.70 | $1,095.70 | $6,813.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.36 / $491.91 / $1,796.98
| Professional | | $381.36 | $491.91 | $1,796.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.01 / $1,166.17 / $2,438.87
| Professional | | $331.01 | $1,166.17 | $2,438.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.72 / $1,034.44 / $1,758.55
| Facility | | $195.72 | $1,034.44 | $1,758.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.44 / $2,232.63 / $2,714.38
| Professional | | $1,171.44 | $2,232.63 | $2,714.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.58 / $2,182.17 / $2,714.38
| Professional | | $1,261.58 | $2,182.17 | $2,714.38 |