- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,290.87
| Professional | | $1,819.70 | $1,819.70 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $1,513.56 / $1,862.09
| Facility | | $54.95 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,548.82 / $5,888.44
| Professional | | $831.76 | $1,548.82 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,513.56
| Professional | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $912.01 / $1,905.46
| Professional | | $758.58 | $912.01 | $1,905.46 |