- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.85 / $7,218.64 / $7,218.64
| Professional | | $985.85 | $7,218.64 | $7,218.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.46 / $1,832.46 / $1,832.46
| Professional | | $1,832.46 | $1,832.46 | $1,832.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,970.26 / $1,970.26
| Facility | | $1,172.51 | $1,970.26 | $1,970.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,602.23 / $1,970.26
| Professional | | $1,172.51 | $1,602.23 | $1,970.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.16 / $1,876.44 / $1,970.26
| Facility | | $1,046.16 | $1,876.44 | $1,970.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,478.77 / $2,117.37
| Professional | | $1,172.51 | $1,478.77 | $2,117.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.10 / $936.14 / $1,071.61
| Professional | | $846.10 | $936.14 | $1,071.61 |