- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,137.96
| Professional | | $1,202.26 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $2,238.72
| Facility | | $144.54 | $144.54 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.28 / $691.83 / $1,318.26
| Facility | | $81.28 | $691.83 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $891.25 / $1,318.26
| Professional | | $831.76 | $891.25 | $1,318.26 |