- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $1,995.26
| Professional | | $1,174.90 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $2,137.96
| Facility | | $144.54 | $144.54 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $144.54 / $2,137.96
| Professional | | $123.03 | $144.54 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $676.08 / $1,288.25
| Facility | | $102.33 | $676.08 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $812.83 / $1,479.11
| Professional | | $562.34 | $812.83 | $1,479.11 |