- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,162.06 / $1,162.06 / $1,162.06
| Professional | | $1,162.06 | $1,162.06 | $1,162.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.95 / $1,301.88 / $1,370.40
| Professional | | $1,205.95 | $1,301.88 | $1,370.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $606.51 / $606.51 / $1,365.47
| Facility | | $606.51 | $606.51 | $1,365.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.51 / $1,320.93 / $2,034.38
| Professional | | $606.51 | $1,320.93 | $2,034.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $815.69 / $1,403.30 / $7,407.45
| Facility | | $815.69 | $1,403.30 | $7,407.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.53 / $697.80 / $1,163.00
| Professional | | $467.53 | $697.80 | $1,163.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.91 / $154.36 / $293.32
| Facility | | $153.91 | $154.36 | $293.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.36 / $191.81 / $364.86
| Professional | | $154.36 | $191.81 | $364.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.28 / $697.80 / $1,104.84
| Professional | | $534.28 | $697.80 | $1,104.84 |