- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.53 / $6,383.12 / $6,383.12
| Professional | | $1,323.53 | $6,383.12 | $6,383.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.28 / $1,972.28 / $1,972.28
| Professional | | $1,972.28 | $1,972.28 | $1,972.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,972.28 / $1,972.28 / $1,972.28
| Facility | | $1,972.28 | $1,972.28 | $1,972.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.85 / $1,972.28 / $2,044.57
| Professional | | $1,325.85 | $1,972.28 | $2,044.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $967.01 / $2,145.65 / $2,245.38
| Facility | | $967.01 | $2,145.65 | $2,245.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.69 / $1,792.21 / $2,585.10
| Professional | | $1,194.69 | $1,792.21 | $2,585.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.50 / $2,112.63 / $3,440.06
| Professional | | $1,683.50 | $2,112.63 | $3,440.06 |