- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,631.09 / $2,631.09 / $2,631.09
| Professional | | $2,631.09 | $2,631.09 | $2,631.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $1,232.84
| Professional | | $1,232.84 | $1,232.84 | $1,232.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $917.34 / $1,442.98 / $2,104.87
| Facility | | $917.34 | $1,442.98 | $2,104.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.95 / $1,996.40 / $5,364.39
| Professional | | $208.95 | $1,996.40 | $5,364.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,037.72 / $1,450.41 / $2,080.94
| Facility | | $1,037.72 | $1,450.41 | $2,080.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $1,232.84
| Professional | | $1,232.84 | $1,232.84 | $1,232.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.81 / $2,357.14 / $4,304.35
| Professional | | $1,229.81 | $2,357.14 | $4,304.35 |