- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.26 / $1,130.26 / $7,239.60
| Professional | | $1,130.26 | $1,130.26 | $7,239.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.88 / $2,283.88 / $2,283.88
| Professional | | $2,283.88 | $2,283.88 | $2,283.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.46 / $2,455.62 / $2,455.62
| Facility | | $1,277.46 | $2,455.62 | $2,455.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,996.93 / $2,455.62
| Professional | | $1,277.46 | $1,996.93 | $2,455.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,049.20 / $2,338.69 / $2,455.62
| Facility | | $1,049.20 | $2,338.69 | $2,455.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.46 / $1,843.06 / $2,457.41
| Professional | | $1,277.46 | $1,843.06 | $2,457.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.55 / $938.86 / $1,082.19
| Professional | | $848.55 | $938.86 | $1,082.19 |