- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.36 / $6,797.73 / $6,797.73
| Professional | | $928.36 | $6,797.73 | $6,797.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,475.71 / $2,475.71 / $2,475.71
| Professional | | $2,475.71 | $2,475.71 | $2,475.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.14 / $2,661.89 / $2,661.89
| Facility | | $1,618.14 | $2,661.89 | $2,661.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.14 / $2,661.89 / $2,661.89
| Professional | | $1,618.14 | $2,661.89 | $2,661.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,229.66 / $2,535.13 / $2,661.89
| Facility | | $1,229.66 | $2,535.13 | $2,661.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.14 / $1,997.86 / $2,663.81
| Professional | | $1,618.14 | $1,997.86 | $2,663.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.49 / $1,100.33 / $1,259.57
| Professional | | $994.49 | $1,100.33 | $1,259.57 |