- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.74 / $1,380.91 / $7,210.49
| Professional | | $984.74 | $1,380.91 | $7,210.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.65 / $2,240.65 / $2,240.65
| Professional | | $2,240.65 | $2,240.65 | $2,240.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.07 / $2,409.15 / $2,409.15
| Facility | | $1,306.07 | $2,409.15 | $2,409.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.07 / $1,959.13 / $2,409.15
| Professional | | $1,306.07 | $1,959.13 | $2,409.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.33 / $2,294.42 / $2,409.15
| Facility | | $1,165.33 | $2,294.42 | $2,409.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.07 / $1,808.17 / $2,566.53
| Professional | | $1,306.07 | $1,808.17 | $2,566.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.47 / $1,042.77 / $1,595.72
| Professional | | $942.47 | $1,042.77 | $1,595.72 |