- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,041.74
| Professional | | $1,621.81 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $1,905.46
| Professional | | $151.36 | $151.36 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $1,905.46
| Facility | | $933.25 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,265.80 / $4,265.80
| Professional | | $1,230.27 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |