- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.07 / $1,986.71 / $2,103.57
| Professional | | $1,123.07 | $1,986.71 | $2,103.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.50 / $1,805.50 / $1,805.50
| Professional | | $1,805.50 | $1,805.50 | $1,805.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.66 / $1,639.62 / $2,962.50
| Professional | | $188.66 | $1,639.62 | $2,962.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.93 / $1,121.15 / $1,778.71
| Professional | | $748.93 | $1,121.15 | $1,778.71 |