- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.02 / $4,158.76 / $4,158.76
| Professional | | $1,199.02 | $4,158.76 | $4,158.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.81 / $1,876.81 / $1,876.81
| Professional | | $1,876.81 | $1,876.81 | $1,876.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.11 / $2,017.94 / $2,017.94
| Facility | | $1,200.11 | $2,017.94 | $2,017.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.11 / $1,641.02 / $2,017.94
| Professional | | $1,200.11 | $1,641.02 | $2,017.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.61 / $1,921.85 / $2,017.94
| Facility | | $803.61 | $1,921.85 | $2,017.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.11 / $1,514.56 / $2,019.41
| Professional | | $1,200.11 | $1,514.56 | $2,019.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.92 / $719.09 / $1,140.48
| Professional | | $649.92 | $719.09 | $1,140.48 |