- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,548.82
| Professional | | $1,258.93 | $1,258.93 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $1,348.96 / $1,621.81
| Professional | | $151.36 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,348.96 / $11,748.98
| Facility | | $758.58 | $1,348.96 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $2,884.03
| Professional | | $1,071.52 | $1,318.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $1,380.38 / $1,659.59
| Professional | | $6.03 | $1,380.38 | $1,659.59 |