- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $1,995.26
| Professional | | $1,202.26 | $1,862.09 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $1,348.96 / $3,981.07
| Professional | | $338.84 | $1,348.96 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,995.26 / $5,011.87
| Facility | | $1,862.09 | $1,995.26 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $10,964.78
| Professional | | $933.25 | $1,318.26 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,511.89
| Professional | | $933.25 | $1,318.26 | $2,511.89 |