- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.32 / $6,188.81 / $6,188.81
| Professional | | $1,784.32 | $6,188.81 | $6,188.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,204.87 / $2,204.87 / $2,204.87
| Professional | | $2,204.87 | $2,204.87 | $2,204.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,576.65 / $2,370.67 / $2,370.67
| Facility | | $1,576.65 | $2,370.67 | $2,370.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.65 / $1,927.86 / $2,370.67
| Professional | | $1,576.65 | $1,927.86 | $2,370.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,046.01 / $2,257.79 / $2,370.67
| Facility | | $1,046.01 | $2,257.79 | $2,370.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.65 / $1,779.30 / $2,372.40
| Professional | | $1,576.65 | $1,779.30 | $2,372.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.97 / $936.00 / $1,560.00
| Professional | | $845.97 | $936.00 | $1,560.00 |