- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.91 / $1,066.34 / $5,647.47
| Professional | | $892.91 | $1,066.34 | $5,647.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.72 / $1,736.72 / $2,084.06
| Professional | | $1,736.72 | $1,736.72 | $2,084.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,736.72 / $1,736.72 / $1,736.72
| Facility | | $1,736.72 | $1,736.72 | $1,736.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.68 / $1,736.72 / $3,104.36
| Professional | | $1,013.68 | $1,736.72 | $3,104.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,070.30 / $1,437.02 / $1,972.77
| Facility | | $1,070.30 | $1,437.02 | $1,972.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.23 / $1,776.12 / $2,959.66
| Professional | | $1,082.23 | $1,776.12 | $2,959.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.89 / $1,848.47 / $2,230.91
| Professional | | $1,497.89 | $1,848.47 | $2,230.91 |