- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.36 / $1,409.49 / $5,479.25
| Professional | | $1,040.36 | $1,409.49 | $5,479.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.58 / $1,662.58 / $1,662.58
| Professional | | $1,662.58 | $1,662.58 | $1,662.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,662.05 / $1,662.05 / $1,662.05
| Facility | | $1,662.05 | $1,662.05 | $1,662.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.27 / $1,662.05 / $1,769.86
| Professional | | $913.27 | $1,662.05 | $1,769.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.85 / $1,130.04 / $1,662.05
| Facility | | $821.85 | $1,130.04 | $1,662.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.41 / $1,662.05 / $2,177.69
| Professional | | $1,006.41 | $1,662.05 | $2,177.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.27 / $1,730.71 / $1,943.67
| Professional | | $1,328.27 | $1,730.71 | $1,943.67 |