- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.21 / $1,102.21 / $1,102.21
| Professional | | $1,102.21 | $1,102.21 | $1,102.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.76 / $1,708.00 / $3,527.00
| Professional | | $1,377.76 | $1,708.00 | $3,527.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,164.07 / $2,164.07 / $2,164.07
| Facility | | $2,164.07 | $2,164.07 | $2,164.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.34 / $1,354.64 / $1,693.30
| Professional | | $551.34 | $1,354.64 | $1,693.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.84 / $440.24 / $1,850.27
| Professional | | $431.84 | $440.24 | $1,850.27 |