- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,398.83 / $3,019.95
| Professional | | $1,584.89 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $2,454.71
| Professional | | $151.36 | $151.36 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,513.56 / $2,511.89
| Facility | | $831.76 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,265.80 / $4,677.35
| Professional | | $1,380.38 | $4,265.80 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,995.26
| Professional | | $1,380.38 | $1,380.38 | $1,995.26 |