- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.55 / $1,927.40 / $2,215.40
| Professional | | $1,661.55 | $1,927.40 | $2,215.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.25 / $2,769.25 / $2,769.25
| Professional | | $2,769.25 | $2,769.25 | $2,769.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.32 / $2,213.19 / $2,980.40
| Facility | | $1,772.32 | $2,213.19 | $2,980.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.93 / $1,329.24 / $11,032.69
| Professional | | $996.93 | $1,329.24 | $11,032.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.93 / $1,329.24 / $3,323.10
| Professional | | $996.93 | $1,329.24 | $3,323.10 |