- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.83 / $1,112.45 / $5,864.55
| Professional | | $913.83 | $1,112.45 | $5,864.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.61 / $1,846.61 / $1,846.61
| Professional | | $1,846.61 | $1,846.61 | $1,846.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,846.61 / $1,846.61 / $1,846.61
| Facility | | $1,846.61 | $1,846.61 | $1,846.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.83 / $1,846.61 / $3,136.93
| Professional | | $1,054.83 | $1,846.61 | $3,136.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,089.51 / $1,464.04 / $2,014.51
| Facility | | $1,089.51 | $1,464.04 | $2,014.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.24 / $1,846.61 / $3,047.71
| Professional | | $1,136.24 | $1,846.61 | $3,047.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.83 / $1,865.61 / $2,361.69
| Professional | | $1,537.83 | $1,865.61 | $2,361.69 |